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

We decided that the Plan does not have to waive the copayments for knee revision surgery and evaluations for 
physical and for occupational therapy provided on May 19 to May 20, 2021.

You asked the Plan to waive the copayments for knee revision surgery and evaluations for physical and for 
occupational therapy. You say that the claim was incorrectly submitted as outpatient rather than inpatient. You 
also say that on your plan benefits there is no limit on physical or occupational therapy. 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 $250 
copayment for each Medicare-covered outpatient surgery or procedure and a $40 copayment for each 
Medicare-covered visit for outpatient rehabilitation services. The Plan contract also says that, unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost 
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an "outpatient."

In this case, the case record indicates that you were provided the services at issue on an outpatient basis. You 
have been asked to pay a $250 copayment for knee revision surgery and a $40 copayment per visit for 
evaluations for physical and for occupational therapy. Knee revision surgery falls within the "Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit 
category and evaluations for physical and for occupational therapy fall within the "Outpatient rehabilitation 
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 copayments for knee revision surgery and 
evaluations for physical and for occupational therapy provided on May 19 to May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve additional physical therapy (PT) visits.

You asked the Plan to pre-approve additional PT visits. You say that you need additional physical therapy to 
address limitations you are still experiencing. The Plan denied your request. 

The Plan says they have agreed to cover 12 of the requested 24 physical therapy sessions; however, the 
remaining 12 visits are not medically necessary. The 12 approved sessions should sufficiently allow you to 
reach your goal and receive further instructions for a home exercise program which is the most important 
aspect to maintain your gains.

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 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 that the additional requested therapy is not generally accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy of 10 outpatient visits with an authorization of 12 additional sessions and the records do not 
demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, and that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist beyond what was approved by the plan. You have been authorized ample therapy to 
be able to transition to a home exercise program. The requested services are not part of a maintenance program, 
and do not require the specialized skill, knowledge and judgment of a qualified therapist 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve twelve additional physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health visits.  

You asked the Plan to pre-approve home health visits. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for additional home health skilled care visits is correct, because the enrollee has been taught a home exercise program and additional home health visits 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 home health visits. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested additional home health visits. Our physician reviewer found the enrollee does not have documented home health physical therapy needs. The enrollee does not have a clearly documented, acute decline in function. The enrollee is functioning at a level commensurate with a lower level of care such as 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 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on May 14, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. 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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.
We find that CPT code R0070 is not supported in the medical record. Specifically, the provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on May 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the provider rendered services to the enrollee in good faith that payment would be made accordingly. You also say that the treating provider has no prior knowledge of the enrollee's insurance and/or authorization as he only sees the enrollee at the time of the service and is referred by the nursing home facility. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says that there are no records of a referral from the enrollee's primary care physician prior to the service being rendered.
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 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 subsequent nursing facility care (99309) provided on March 19, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 12, 2020.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.  

The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.  

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant, providing care in the home; per hour, (S9122) provided from December 10, 2020, to December 15, 2020.

You asked the Plan to reimburse you for the home health services. You say that you tried for months to get an aide to help the enrollee. You say that this provider was willing to help. You say that the provider did not advise they were not Medicare certified. You also say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is not included on the list of home health agencies that service the enrollee's area. The Plan says there were certified provider's available for the enrollee to utilize. The Plan also says that there are no authorization on file for the home health services.

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 reimburse you for the home health aide or certified nurse assistant, providing care in the home; per hour, (S9122) provided from December 10, 2020, to December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 8, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as the services were superficial. 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 $40 copayment for Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that these services were performed by a specialist. 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 specialist office visit provided on June 8, 2021.

Your complaint about the services not being substantial 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308 and 99309) provided from July 7, 2021, to July 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you have re-applied for in-network status, but the Plan denied without cause. You also say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these services were rendered by a provider who is not under contract with the Plan. The Plan also says that the services rendered were not approved in compliance with the Plan's authorization procedure.

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 subsequent nursing facility care (99308 and 99309) provided from July 7, 2021, to July 21, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal orthosis (back brace).
You asked the Plan to pre-approve back brace. You say that this brace is critical for the enrollee's post-surgery recovery. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because payment for this orthosis would be included in the payment to the hospital if dispensed prior to a hospital stay and needed for use after surgery.
The Plan follows Medicare rules. Medicare rules state that spinal orthoses may be covered under certain conditions. 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 back brace. Our reviewer says that the enrollee does not meet the Medicare criteria for this back brace. Our physician reviewer found the documentation does not reveal evidence on a physical exam that indicates the enrollee's pain is reduced by restricting trunk mobility. There is no evidence of a recent injury to the spine or related soft tissues that requires the orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal muscles. The brace is being requested ahead of a surgery planned for January 19, 2022. At this
point the enrollee has not had the surgery therefore it is not evident at this time that the patient requires this
brace to facilitate healing following a surgical procedure on the spine or related soft tissue. Additionally, the
documentation notes that this is a custom fitted orthosis and the enrollee will need to be fitted preoperatively in
the office for the brace; however, the physical exam documentation does not reveal extenuating factors that
would require a custom fitted orthosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of back brace have not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal orthosis (back brace).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 25, 2021, to July 29, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were not informed of this copayment requirement beforehand, and you cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with your contract. There is a $250 copayment for each of the first four days of an inpatient admission.
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 $250 copayment for each of the first four days of an inpatient hospital stay.
You have been asked to pay a $1,000 copayment for the four-day inpatient hospital stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 25, 2021, to July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for out of network services provided on May 20, 2021.  

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network services provided to the enrollee on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on July 2, 2021, by an OON provider.  You asked the Plan to pay for the nursing facility care. You say that you are requesting review and reconsideration for payment due to the fact that this enrollee resides in a nursing home and your provider provides acute visits to the nursing home. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 subsequent nursing facility care (99309) provided on July 2, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a rotator cuff surgery provided on April 12,
2021.
You asked the Plan to waive the copayment for a rotator cuff surgery. You say that you are disputing all the
copayments because you need a repeat surgery due to the fault of the physical therapist. The Plan denied your
request. The Plan says the correct copayment was 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 $150
copayment for each Medicare-covered outpatient surgery or procedure.
You have been asked to pay a $150 copayment for a rotator cuff surgery. A rotator cuff surgery 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.
Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care
received. Therefore, we decided that the Plan does not have to waive the copayment for a rotator cuff surgery
provided on April 12, 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.