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

 We decided that the Plan does not have to pay for the nerve conduction studies coded 95907, the needle electromyography coded 95886, and the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on March 18, 2020.  You asked the Plan to pay for the nerve conduction studies, the needle electromyography, and the unlisted neurological or neuromuscular diagnostic procedure. 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 supported by 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.  We find that CPT codes 95907, 95886, and 95999 are not supported in the medical record. Specifically, 1-2 nerve conduction studies are not supported by the documentation; therefore, code 95907 cannot be verified. The technical report did not include documentation of a complete needle electromyography; therefore, code 95886 cannot be verified. Lastly, the technical report did not include documentation of unlisted neurological or neuromuscular diagnostic procedure; therefore, code 95999 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies, the needle electromyography, and the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95907, the needle electromyography coded 95886, and the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90834) rendered by the out-of-network (OON) provider on May 7, 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 psychotherapy (90834) rendered by the out-of-network (OON) provider on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a third level of a radiofrequency ablation for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical information provided to explain why the third level is being requested.  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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical provided to explain why the third level is being requested (L5-S1). There is no documentation of medical necessity or why an exception should be made. The review has determined that there are no unique clinical circumstances to consider a third level of radiofrequency ablation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of a radiofrequency ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for heart monitoring services provided in a cardiologist's office on July 1, 2021.  You asked the Plan to waive the copayment for the heart monitoring services. You say that this copayment should be waived because the doctor had an emergency and was not seeing patients.  You said you left the office because there was no one in the office. 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 $5 copayment for services in a specialist's office.   We looked at the medical records from this date of service.  Although you may not have physically seen the doctor, you did receive heart monitoring services on this date. 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 heart monitoring services provided in a cardiologist's office on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you need therapy and monitoring. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral x-ray and extraction provided on June 30, 2021.  You asked the Plan to pay for the intraoral x-ray and extraction. You say that you were referred by a dentist that was supposed to be in-network and you considered this an emergency because you had an abscessed tooth. You say that this claim shouldn't have been denied. The Plan denied your request. The Plan says there is no coverage when services are rendered by an out-of-network provider.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray and extraction provided on June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from November 25, 2021, forward.  You asked the Plan to pre-approve SNF care. You say that the enrollee still has their stomach-ache, and they are seeing a gastrointestinal (GI) doctor on November 30, 2021, and ask that they be allowed to continue their skilled stay until things are figured out. The Plan denied your request. The Plan says the enrollee's plan of care has stabilized, and the enrollee no longer has a daily skilled need.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from November 25, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for radiation therapy services provided from June 28, 2021 through August 17, 2021.  You asked the Plan to waive the copayment for the radiation therapy services. You say that these were processed as an office call, but these are for treatments. You say that you were only seeing the doctor one day per week and are being charged a copayment for each treatment. The Plan denied your request. The Plan says the claims reprocessed to apply a $25 copayment for each radiation therapy visit.  The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $25 copayment for diagnostic and therapeutic radiology services.   You have been asked to pay a $25 copayment for each radiation therapy treatment. The total amount you owe is $900 ($25/visit x 36 visits = $900). The radiation therapy services fall 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 radiation therapy services provided from June 28, 2021 through August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmic biometry services you received on July 6, 2021.  You asked the Plan to waive the copayment for the ophthalmic biometry services. You say that you should not have to pay this copayment because it was a pre-op visit. 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 $35 copayment for vision care services in a specialist's office.   You have been asked to pay a $35 copayment for the ophthalmic biometry services. Medicare rules state that only pre-operative visits on the day before or the day of surgery are included in the cost of the surgery itself.  All other pre-operative visits are separately payable and separate copayments can apply. The services in question occurred more than a week prior to your surgery, so any pre-operative visit on this date would also have separate cost sharing. Notwithstanding that rule, the provider did not bill for a pre-operative visit on July 6, 2021.  Rather, they billed for ophthalmic biometry services, which are services to measure the curvature of the eye.   The ophthalmic biometry services fall within the vision care services in a specialist's office 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 ophthalmic biometry services you received on July 6, 2021.   Your complaint about a $71 charge for services on July 16, 2021, has not been sent to us for review by the Plan. Because it does not appear as though the Plan has processed an appeal at its level for this service, Maximus has no jurisdiction to review it. Therefore, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on July 7, 2021.

You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services provided out of network are not covered. The Plan also says you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 18, 2021, to May 22, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you find it hard to believe that this amount represents your copayment. You stated that you have Medicaid and believe all of your copays are paid by them. 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 $305 copayment per day for days 1-7 for inpatient hospital services. 

Records show that you were in the hospital for 4 days. You were charged a $305 copayment per day, for a total of $1220. 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 you received from May 18, 2021, to May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 27, 2021.  You asked the Plan to pay for the limited oral exam. You say that you were referred to see the surgeon following a regular visit with your dentist. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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. The Plan covers the limited oral exam once per plan year.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that a limited oral exam was covered on July 12, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and flexible protective outer surface covering system (L5962) for a lower limb prosthesis.  You asked the Plan to pre-approve flex-walk system and flexible protective outer surface covering system. You say that you need this to continue doing activities you like and maintaining your quality of life. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because the records do not show why an advanced foot and cover are needed.  The Plan must follow Medicare rules. Medicare rules state that a flex-walk system is covered for enrollees whose functional level is 3 or above, as described in the prior section. 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 flex-walk system and flexible protective outer surface covering system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you use a rollator walker for ambulation in the community due to your visual impairment. Your treating provider's notes do not document the need for ambulation with variable cadence or that you have the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demand prosthetic utilization beyond simple locomotion.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of flex-walk system and flexible protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk system (L5981) and flexible protective outer surface covering system (L5962) for a lower limb prosthesis.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided February 22, 2021, March 17, 2021, and April 13, 2021, and the ambulance service, basic life support, emergency transport (A0429) provided June 1, 2021.  You asked the Plan to waive the copayment for the emergency and nonemergency ambulance transports. You say that the transports were medically necessary. The Plan denied your request. The Plan says the claims have been reprocessed and the copayments have 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip.   The enrollee has been asked to pay a total of $1,000 ($250 copayment x 4 trips = $1,000) for the emergency and nonemergency ambulance transports. These ambulance transports fall within the Ambulance services 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 copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided February 22, 2021, March 17, 2021, and April 13, 2021, and the ambulance service, basic life support, emergency transport (A0429) provided June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the shoe inserts.  You asked the Plan to pre-approve the shoe inserts. You say that you believe these inserts should be covered because you have flat feet and every day it is a pain t walk without them. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan states the requested shoe inserts are not part of a leg brace.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for nutria-pharmaceutical blend injections (96372, J3490-KP, J3490-KQ-59) provided on March 25, 2021.  You asked the Plan to pay for nutria-pharmaceutical blend injections. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.   We looked at the file and Medicare rules. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of nutria-pharmaceutical blend injections have not been met. Therefore, we decided that the Plan does not have to pay for nutria-pharmaceutical blend injections (96372, J3490-KP, J3490-KQ-59) provided on March 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on June 15, 2021, billed with code 71048.  You asked the Plan to pay for the chest x-ray interpretation. You say that the record supports the billing of code 71048. The Plan denied your request. The Plan says this code is 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 code 71048 is Radiologic examination, chest; 4 or more views.  We find that CPT code 71048 is not supported in the medical record. Specifically, the imaging report clearly documents that the chest x-ray was a single, frontal view. There is no documentation of 3 or more views of the chest for this x-ray.  Based on this information, we decided that Medicare rules for coverage of the chest x-ray interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the chest x-ray provided on June 15, 2021, billed with code 71048.