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

 We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) with doppler provided on August 6, 2021.  

You asked the Plan to waive the copayment for the TTE with doppler. You say that you feel that you should not be responsible for the copayment since it was not collected at the time of service according to the provider's billing rules. 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 $10 copayment for outpatient diagnostic tests.      

You have been asked to pay a $10 copayment for the TTE with doppler. The TTE with doppler 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 a transthoracic echocardiography (TTE) with doppler provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 18, 2020, to August 20, 2020.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel that the Plan should cover the full cost. 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 $289 per day for days 1-6 and $0 per day for days 7-90 for each inpatient stay.   The file shows that you were in the hospital from August 18, 2020, to August 20, 2020, but there is no copayment for the discharge date. Therefore, you have been asked to pay $289 per day for the first 2 days of inpatient hospital services. The total for your stay is $578 ($289 copayment x 2 days = $578). The inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from August 18, 2020, to August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laparoscopic hernia repair (49652) provided on April 9, 2021.   You asked the Plan to pay for the laparoscopic hernia repair (49652). You say that the operative report clearly states there were two different hernia repairs for this patient. You say that the claim should be reprocessed for reimbursement. The Plan denied your request. The Plan says the benefit for this service is included in the payment for 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, we have confirmed that code 49652 is a column II code to column I code 49653. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopic hernia repair (49652) provided on April 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the emergency room visits provided on August 16, 2021, and August 17, 2021.  You asked the Plan to waive the copayments for the emergency room visits. You say that you should not be charged a copayment for each visit because it was about the same problem. The Plan denied your request. The Plan says the enrollee was never admitted as an inpatient to a hospital, so the emergency room copayment was properly 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 $90 copayment for emergency care visits. The total copayment amount for both visits was $180 ($90 copayment + $90 copayment).    You have been asked to pay a $180 copayment for the emergency room visits. The emergency room visits falls within the Emergency care 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 the emergency room visits provided on August 16, 2021, and August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214), a fundus photography (92250), a gonioscopy (92020) and an ophthalmic ultrasound (76514) provided on April 12, 2021,  by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit, a fundus photography, a gonioscopy and an ophthalmic ultrasound. You say that you are requesting reconsideration of this denied claim based on medical necessity. The Plan denied your request. The Plan says the rendering provider, who is also the referring provider, is a non-participating provider with the Plan. The Plan also says they denied the claim due to no prior authorization for date of service.  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 (99214), a fundus photography (92250), a gonioscopy (92020) and an ophthalmic ultrasound (76514) provided on April 12, 2021,  by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee did not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on September 15, 2021.  You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that due to the quality of care you received, you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for outpatient surgery provided at hospital outpatient facilities and ambulatory surgical centers.   You received a fine needle aspiration biopsy on September 15, 2021, at an outpatient hospital facility. A fine needle aspiration biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment.   You have been asked to pay a $300 copayment for a fine needle aspiration biopsy. A fine needle aspiration biopsy 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 a fine needle aspiration biopsy provided on September 15, 2021.   Your quality of care concerns have been handled separately by the Plan. Medicare does not permit Maximus to make a decision on this type of complaint.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on July 20, 2021.  

You asked the Plan to pay for lab tests. You say that you are appealing with records to justify the services provided. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the Plan is the secondary payer and cannot process this claim until the primary payer explanation of benefits is received.  

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you to send the bill to the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for lab tests until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 20, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy requirements have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the requirements for coverage of Prolia have been met. Our physician reviewer found the Plan requires a trial of drug zoledronic acid or a history of osteoporotic fracture before they will approve the requested drug. While based on the medical records provided the patient has not tried and failed zoledronic acid, there is evidence of an osteoporotic compression fracture of the T9 vertebral body on the May 2018 dual energy x-ray absorptiometry scan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of a spinal distraction device (Vertiflex Superion interspinous spacer at L4-5).  You asked the Plan to pre-approve insertion of a spinal distraction device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  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 insertion of a spinal distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal stenosis, lumbar region with neurogenic claudication. The enrollee presented with low back pain bilaterally with radiation into right flank. The enrollee had a lumbar magnetic resonance imaging (MRI) on October 28, 2021. However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis (which have not been adequately addressed in the medical records.) Therefore, the enrollee does not meet criteria for the requested services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a spinal distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a spinal distraction device (Vertiflex Superion interspinous spacer at L4-5).
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the neuromonitoring services (95957, 95908, and 95885) provided on September 11, 2020.  You asked the Plan to pay for codes 95957, 95908, and 95885. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for codes 95957, 95908, and 95885 by a contract provider. The file does not show that the plan provided notice that codes 95957, 95908, and 95885 would not be covered. Under Medicare rules, this means codes 95957, 95908, and 95885 are considered approved by the plan. Therefore, we decided that the Plan has to pay for the neuromonitoring services (95957, 95908, and 95885) provided on September 11, 2020.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 15, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 24, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the continuous positive airway pressure (CPAP) device (E0601), the positive airway pressure filter (A7038), and the special services (99199) purchased from the out-of-network (OON) provider on September 22, 2021.  You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items/services were purchased from 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 issue reimbursement 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 items/services at issue. We found no exception that would require the Plan to issue reimbursement for these items/services. Therefore, we decided that the Plan does not have to issue reimbursement for the continuous positive airway pressure (CPAP) device (E0601), the positive airway pressure filter (A7038), and the special services (99199) purchased from the out-of-network (OON) provider on September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusions (99601 and 99602) provided on June 3, 2021.  You asked the Plan to pay for the home infusions (99601 and 99602). You say that this provider is participating with the Plan and the claim incorrectly processed out-of-network. You say that the claim should be reprocessed at the in-network level. The Plan denied your request. The Plan says the billed codes are not valid for Medicare purposes.  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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure).  We find that CPT code 99601 and 99602 are not supported in the medical record. Specifically, CPT codes 99601 and 99602 have a status indicator of I. This means that CPT codes 99601 and 99602 are not valid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusions (99601 and 99602) have not been met. Therefore, we decided that the Plan does not have to pay for the home infusions (99601 and 99602) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and vertical bitewing x-rays, 7 to 8 images (D0277) provided on June 28, 2021.  You asked the Plan to pay for the dental services. You say that you were unaware that the provider was out of network. You also say that the dental office advised your insurance was accepted. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.  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, dental services received by a provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and vertical bitewing x-rays, 7 to 8 images (D0277) provided on June 28, 2021.