Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), four periodontal scalings and root planings (D4341 x4), four gingival irrigations (D4921 x4), and periodontal medicament carrier with peripheral seal (D5995) provided on May 11, 2021.  
You asked the Plan to pay for the comprehensive oral evaluation, scalings and planings, gingival irrigations, and periodontal medicament. You say that the treating provider never rendered these services, but you are being charged for them. The Plan denied your request. The Plan says that the records submitted by the provider appear to be incomplete. The Plan also says that additional records were requested and not received.  
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.  You were referred for the comprehensive oral evaluation, scalings and planings, gingival irrigations, and periodontal medicament by a contract provider. 
The file does not show that the Plan provided notice that the comprehensive oral evaluation, scalings and planings, gingival irrigations, and periodontal medicament would not be covered. There was no proof provided by the Plan or Plan contracted provider (such as medical records) to show that the services at issue were provided. Under Medicare rules, this means the comprehensive oral evaluation, scalings and planings, gingival irrigations, and periodontal medicament is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150), four periodontal scalings and root planings (D4341 x4), four gingival irrigations (D4921 x4), and periodontal medicament carrier with peripheral seal (D5995) provided on May 11, 2021.   
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 waive the cost share for the medical eye exam and the Part B drug provided on May 4, 2021.  You asked the Plan to waive the cost share for the medical eye exam and the Part B drug. You say that you are on a limited income and trying to save your wife's vision with this treatment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.   The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for all other Medicare-covered vision services and 20% coinsurance in-network Medicare-covered Part B chemotherapy drug and other Part B drugs.   The enrollee has been asked to pay a $35 copayment for the medical eye exam and $367.55 which is 20%   of the allowed amount for the Part B drug. The allowed amount is $1,837.74. ($1,837.74 x 20% = $367.55). ($367.55 + $35 = $402.55). The medical eye exam falls within the "Vision care" benefit category. The Part B drug falls within "Medicare Part B prescription drugs" benefit category.   This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the medical eye exam and the Part B drug provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the subcutaneous tissue debridement (11042 x 2) provided on August 6, 2021 and August 23, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $325 copayment per date of service for outpatient surgery at an outpatient hospital facility.    You have been asked to pay $650 ($325 x 2) for the outpatient surgeries provided at an outpatient hospital facility. 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 subcutaneous tissue debridement (11042 x 2) provided on August 6, 2021 and August 23, 2021.
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 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 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 IRF admission is not medically necessary based on lack of medical complexity and with no rehabilitation nursing needs. Documentation does not support the necessity for admission to IRF. 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from April 21, 2021, through April 27, 2021 with the reported principal diagnosis A41.9, sepsis, unspecified organism.  You asked the Plan to pay for inpatient services provided from April 21, 2021, through April 27, 2021 with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says the admission was due to the enrollee's sick gallbladder. He had his gallbladder removed and after surgery, and it took some time for his digestive tract to work. The enrollee did not have any infection and he did not have any kidney problems.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis A41.9, sepsis, unspecified organism. 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 pay for inpatient services provided from April 21, 2021, through April 27, 2021 with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee was a then a 75-year-old male who presented to the emergency department (ED) on April 21,2021 with Right Upper Quadrant (RUQ) pain and nausea. He was found to have cholecystitis, no calculus. He has a history of bladder cancer and recent trans urethral resection of bladder tumor (TURBT).  His vitals were: blood pressure 209/91, Oxygen saturation 98% RA, Temperature was 98.7, pulse was 80 Resp 18, Labs: Platelets 217, Cr. 1.4, baseline Cr 1.1, white blood cell 16.4,  Lactic acid 1.4, Blood culture was negative, Urine culture was negative, Bili .4, and Procalcitonin .41.  Sepsis 1 criteria were not met, only with leukocytosis. The enrollee had sequential organ failure assessment (SOFA) score of 1 with an elevated creatinine, however the enrollee had hypertensive urgency. He underwent laparoscopic cholecystectomy, and the only complication before discharge was an ileus post operative. The review has determined that the principal diagnosis A41.9, Sepsis, unspecified organism, was not supported by the medical records.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from April 21, 2021, through April 27, 2021 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) testing rendered on April 19, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has tinea unguium and a request was made for PCR testing for toenail fungus. Based on current evidence on PCR testing methods for infectious diseases, this method of testing has not yet been shown to lead to improved end-outcomes compared to standard testing methods (culture and sensitivity) to justify this testing method at this time. The submitted records did not sufficiently support this case as an exception. The services were therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the polymerase chain reaction (PCR) testing rendered on April 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the echocardiography, transthoracic, real-time with image documentation (93306) provided April 22, 2021.  You asked the Plan to reduce the copayment for the echocardiography. You say that you feel you should have a $30 copayment, not a $125 copayment. The Plan denied your request. The Plan says the copayment has been 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 $125 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or a free-standing facility.  You have been asked to pay a $125 copayment for the echocardiography. This service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. An echocardiography is considered a radiological diagnostic service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the echocardiography, transthoracic, real-time with image documentation (93306) provided April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) scan of the lower extremity without contrast (73718) provided on July 23, 2021.  You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $250 copayment for each Medicare-covered advanced imaging service.     You have been asked to pay a $236.71 copayment for the Medicare-covered advanced imaging service provided. This is the Plan's allowed amount for this service which is less than the applicable 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 adjust the copayment for the magnetic resonance imaging (MRI) scan of the lower extremity without contrast (73718) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital visit (99232) provided on August 8, 2021.  You asked the Plan to pay for code 99232. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. Code 99232 is an inpatient hospital care code. The claim should be billed with the correct place of service code for inpatient services. Therefore, we decided that the Plan does not have to pay for the inpatient hospital visit (99232) provided on August 8, 2021.   We note that it appears a corrected claim was submitted directly to Maximus during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional eyeglass upgrades, polarization, any lens material, per lens (V2762) and Lens, polycarbonate (V2784) provided on August 9, 2021.  You asked the Plan to pay for additional eyeglass upgrades. The Plan denied your request. The Plan says you have exhausted the vision benefit.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file, Medicare rules and the Plan's rules. The file shows that the Plan covered the progressive lenses with a $50 copayment per the vision benefit upgrade. The Plan does not cover additional upgrades. Medicare says polarization (V2762) will be denied as noncovered and the use of polycarbonate or similar material (V2784) will be denied as a noncovered deluxe feature. Therefore, we decided that the Plan does not have to pay for additional eyeglass upgrades, polarization, any lens material, per lens (V2762) and Lens, polycarbonate (V2784) provided on August 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the behavioral health services provided from August 1, 2021 to August 9, 2021.  You asked the Plan to pay for the behavioral health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you are not enrolled in the Medicare program.  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 pay for the behavioral health services provided from August 1, 2021 to August 9, 2021.
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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 medical records show the enrollee is stable and does not meet Medicare coverage criteria for an IRF admission.   With his current medical stability, and no other acute medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs noted in the record. He does 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. IRF admission is not medically necessary based on lack of medical complexity and limited tolerance to activity due to pain with no rehab nursing needs. Document does not support the necessity for admission to an IRF 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on  August 25, 2021.  You asked the Plan to pay for the surgical extraction. You say that you had your tooth pulled because it was cheaper. You also say that you have been enrolled with this plan since 2020, had to pay $34 per month for 17 months, and when you do use the insurance, all the Plan pays for is exams and x-rays. The Plan denied your request. The Plan says this service is not a covered benefit.  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 the surgical extraction (D7210) provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on April 21, 2021, and April 22, 2021.  You asked the Plan to pay for the self-administered drugs. You say that these medications were provided to you by the nurse at the hospital, not your own personal home medications. You also say that these oral medications are equally as important as any other medication and you would like payment to be reconsidered. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on April 21, 2021, and April 22, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (procedure code 00732, 99100) provided to the enrollee on March 4, 2021.  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 the denied codes remain not supported.  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 the denied codes is:  CPT 99100:  Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)  CPT 00732:  Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in terms of CPT 00732, the documentation submitted was only a report for anesthesia services. The anesthesia report documents "EUS ERCP" procedure. If EUS ERCP was performed, then CPT 00732 would be the correct code to report for anesthesia services. However, an EUS ERCP was not performed on this date of service, and (CPT 47533) a placement of biliary drainage catheter was performed was reported, which CPT 00700 should be reported. In terms of CPT 99100, this code is ineligible for separate reimbursement in addition to code for primary anesthesia procedure. The codes are assigned a status indicator of "B" (bundled code) on the CMS Physician Fee schedule, and are not eligible for separate reimbursement under Medicare guidelines. There are no RVUs or payment amoount for these codes and separate payment is not made.  We looked at this coder's review, the file, and Medicare rules. 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 anesthesia services (procedure code 00732, 99100) provided to the enrollee on March 4, 2021.