Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve the walk-in bathtub. You say that you need the walk-in tub to minimize fall risks. The Plan denied your request. The Plan says walk-in bathtubs are not covered by the Plan or Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a complete ultrasound scan of the pelvis (76856) provided on June 2, 2021.
You asked the Plan to waive the copayment for a pelvic ultrasound. You say that you do not feel you should have to pay for the ultrasound because the radiologist clearly stated that the lesion described in his report would likely not be visible with an ultrasound and suggested a Computed Tomography (CT) scan instead. You say getting both imaging services would benefit the performing facility, so the radiologist was bypassing fees by recommending the CT scan. The Plan denied your request. The Plan says the cost-share was 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 $150 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You have been asked to pay a $99.78 copayment for a pelvic ultrasound. A pelvic ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan's Allowed Amount is less than the required $150 copayment.
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 a complete ultrasound scan of the pelvis (76856) provided on June 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 4 hours per day of home health aide
services (G0156).
You asked the Plan to pre-approve home health aide services. You say that the requested services are a medical
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested
services have not been met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our
reviewer says that the request is not medically reasonable and necessary in this case. Our physician reviewer
found that the documentation does not support that you require skilled nursing services or skilled rehabilitation
services to provide treatment that is medically necessary.
You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in
order to improve your condition, perform a maintenance program to maintain your condition, and/or prevent
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations. The approved home health assistance of 1.5 hours daily is adequate to support you with
activities of daily living (ADLs) and instrumental ADLs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve an additional 4 hours per day of home health aide services (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided on July 6, 2021.
You asked the Plan to pay for a complete series of radiographic images. You say that you did not know there was an extra charge for the x-rays. You also say you would not go to a dentist where your benefits were not available. The Plan denied your request. The Plan says there is no coverage for a complete series of radiographic images.
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. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided on July 6, 2021.
Your complaint about the care you received 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $30 copayments charged for specialist office injection
services provided on February 18, 2021 and February 25, 2021.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says these copayments were charged based on the Plan contract
agreement and the services provided. Maximus overturned the Plans denial because the Plan contract submitted
with the case file did not reflect the $30 copayment. The Plan requested a reopen and submitted the correct
contract information for review.
The Plan is correct in this case. 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 in a specialist office.
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 $30 copayments charged for specialist office injection services provided on
February 18, 2021 and February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement of subcutaneous tissue (11042) provided on April 9, 2021.
You asked the Plan to waive the copayment for removal of skin and tissue. You say that you were never informed of the service being considered outpatient surgery and were under the impression you would only have to pay a $30 copayment for a specialist visit. You say that you cannot afford unexpected medical bills. The Plan denied your request. The Plan says the cost-share was applied correctly. The provider billed for debridement of the skin, which is classified as a surgical procedure by the American Medical Association.
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 Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.
You have been asked to pay a $275 copayment for removal of skin and tissue received in an outpatient hospital setting. This service falls within the Outpatient Surgery, Including 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 copayment for debridement of subcutaneous tissue (11042) provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (0012M) provided April 28, 2021.
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this procedure is non-covered.
The Plan must follow Medicare rules. Medicare rules say that non-coverage of code 0012M for Cxbladder was reaffirmed by Medicare. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (0012M) provided April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services provided on February 16, 2021.
You asked the Plan to pay for refraction services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says refraction services are not a covered benefit. Maximus overturned
the Plans denial stating incorrect contract information had been submitted. The Plan requested a reopen and
provided additional information.
The Plan is correct in this case. Medicare does not cover refraction services. The Plan contract does not list
refraction services as a covered benefit. Therefore, we decided that the Plan does not have to pay for refraction
services provided on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of the arm you had on June 10, 2021.
You asked the Plan to waive the coinsurance for the CT scan. You say that this has been submitted to Medicaid several times, but it has been denied. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiological diagnostic services.
You have been asked to pay 20% coinsurance for the CT scan. the CT scan falls within the radiological diagnostic 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 coinsurance for the computed tomography (CT) scan of the arm you had on June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided from March 18, 2021, to March 31, 2021.
You asked the Plan to pay for the additional supplies, materials, and clinical staff time. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not eligible for coverage when billed in conjunction with another service.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99072. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical staff time have not been met. Therefore, we decided
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided
from March 18, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (01630) provided on October 7, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is not supported in the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 01630 is not supported in the medical record. Specifically, no medical records were received to demonstrate that the services were billed correctly. Without these medical records, the claim cannot be corroborated as billed. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (01630) provided on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from January 19, 2021, to March 1, 2021.
You asked the Plan to waive the copayment for the SNF services. You did not provide an explanation for your appeal with your request. 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 $0 copayment per day for days 1-20, and a $140 copayment per day for days 21-100 for skilled nursing facility services..
REcords show that you were in the SNF for a total of 41 days. You were not charged a copayment for the first 20 days in accordance with your contract. You were then charged a $140 copayment per day for the remaining 21 days, for a total of $2940. YThis 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 skilled nursing facility (SNF) services you received from January 19, 2021, to March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by a provider who has opted out
of the Medicare program provided on January 12, 2021.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the dental provider in this case has opted out of
the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental
services provided by a provider who has opted out of the Medicare program provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on January 19, 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 (99203) rendered by the out-of-network (OON) provider on January 19, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve out of network rheumatology services.
You asked the Plan to pre-approve continued out of network rheumatology services. You say that treatment with this provider is medically necessary. The Plan denied your request. The Plan says that this treatment can be provided in network.
The Plan must follow Medicare rules. Medicare rules out of network services are covered when determined medically necessary. 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 out of network rheumatology services. Our reviewer says that medical necessity has been established. Our physician reviewer found there is a diagnosis of inflammatory polyarthritis and Crohn's disease. You are receiving Xeljanz. The Plan has determined that there are in-network providers that can offer the same care being received. The provider writes that due to the complicated medical history and the fact that you are on immunosuppressive medication, it is in your best interest to continue care with her current specialist. The provider notes that you had previously seen an in-network rheumatologist and did not receive satisfactory care and ended up in the hospital. Therefore, continued care with the out of network specialist has been determined to be medically necessary. You are receiving active treatment and/or medical management of your condition that makes it medically necessary to continue and the medical management and/or follow-up care cannot be safely transitioned to an in-network specialist at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out of network rheumatology services have been met. Therefore, we decided that the Plan has to pre-approve out of network rheumatology services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a medical boot (L4361) provided on June 24, 2021.
You asked the Plan to waive the coinsurance for a medical boot. You say that there should be no charge and feel the plan is billing more so that you have a copayment. The Plan denied your request. The Plan says the coinsurance applied successfully based on the allowed amount ($345.83).
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 Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for a medical boot (20% of 345.83 = $69.17). Medical boots fall within the Durable medical equipment (DME) and related 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 coinsurance for a medical boot (L4361) provided on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical system coded S2900 provided on May 20, 2021.
You asked the Plan to pay for the surgical techniques requiring use of robotic surgical system. 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 S2900 is surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure).
We find that CPT code S2900 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 surgical techniques requiring use of robotic surgical system have not been met. Therefore, we decided that the Plan does not have to pay for the surgical techniques requiring use of robotic surgical system coded S2900 provided on May 20, 2021.