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

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided on September 1, 2020, through September 22, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXF1.
You asked the Plan to pay for the SNF services billed with PDPM GAXF1. You say that you would like reconsideration because the submitted documentation supports the PDPM code billed. The Plan denied your request. The Plan says I0020B and section GG are missing in the submitted documentation.
The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM GAXF1 have not been met. Specifically, the records submitted are missing required information from Section GG of the Minimum Data Set. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided on September 1, 2020, through September 22, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXF1
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and additional surgical extraction (D7210) provided on October 4, 2021.
You asked the Plan to pay for the gingival irrigation and additional surgical extraction. You say that your dental benefits include one tooth extraction per year, but you had two teeth removed and you believe the dentist submitted the claim for both teeth instead of just one. The Plan denied your request. The Plan says the gingival irrigation is not covered by your health plan. The Plan also says that you have exhausted your benefit coverage for the surgical extraction.
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, gingival irrigation (D4921) is not among those covered under this benefit. The contract says that you are limited to 1 extraction per year. The record shows that you received two extractions on October 4, 2021, one of which was covered by the Plan, and your extraction benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) and additional surgical extraction (D7210) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee.
You asked the Plan to pre-approve hyperbaric oxygen (HBO) therapy. You say that this treatment is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
Medicare guidelines.
Our Medical Director reviewed the case file and the reopen request. At issue is coverage for hyperbaric oxygen
(HBO) therapy. The Maxims Physician Reviewer determined that this treatment is considered medically
reasonable and necessary in this case. The Plan argues there was no evidence of preparation for or preservation
of a compromised skin graft, or chronic refractory osteomyelitis which was unresponsive to conventional
medical and surgical management. The Plan states the enrollee had not failed 30 days of standard wound care
to include vascular assessment, adequate debridement, or treatment to resolve known infection.
The medical records show the enrollee had a history of diabetes, smoking, sleep apnea, and chronic
demyelinating polyneuritis. The enrollee has a foot ulcer with a wound on his right second toe. The wound was
debrided on May 21, 2021. It was noted that the enrollee was at very high risk for amputation. The wound was
Grade 3 on the Wagner Scale, and the enrollee had been receiving treatment for 3 weeks.
Our Medical Director has concluded that the Plan is correct in this case. The available documentation in the
case file does not support that the enrollee had failed an adequate course of standard therapy, defined as no
measurable signs of healing for at least 30 consecutive days.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hyperbaric oxygen (HBO) therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on August 3, 2021, to August 6, 2021.
You asked the Plan to waive the copayment for an inpatient hospital. You say that you went in on August 4th
and was discharged on the 6th. The Plan denied your request. The Plan says the correct copayment has been
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 $325
copayment per day for days 1-5. There are no charges for additional days for inpatient hospital care.
You have been asked to pay a $325 copayment per day for days 1-3 for an inpatient hospital. The total amount
you are being asked to pay is $975 ($325 x 3 days =$975). Evidence was provided that shows the correct
copayment has been applied to the length of stay that was provided. An inpatient hospital falls 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 an inpatient
hospital stay provided by a participating provider on August 3, 2021, to August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, hip, LT (73502) radiologic examination, hip, RT (73502) provided July 26, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you feel that the Plan should cover your x-rays. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $50 copayment for each Medicare covered standard x-ray service. You have been asked to pay $80.80 ($40.40 + $40.40) for the diagnostic service. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. The diagnostic service 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 radiologic examination, hip, LT (73502) radiologic examination, hip, RT (73502) provided July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the vedolizumab injections (J3380 x 3) and the laboratory service (86480) provided from February 17, 2021, through June 16, 2021.
You asked the Plan to waive the cost share 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 cost share has 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 20% coinsurance for chemotherapy drugs and for all other drugs covered under Medicare Part B. Additionally, you must pay a $20 copayment for laboratory services. You have been asked to pay $3,721.40 which includes the Plan allowed amount of $18,507 x 20% coinsurance=$3,701.40 for the Medicare Part B drugs provided on February 17, 2021, April 16, 2021, and
June 16, 2021. Additionally, this amount includes a $20 copayment for the laboratory service provided on
May 27, 2021. 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 cost share for the vedolizumab injections (J3380) and the laboratory service (86480) provided from February 17, 2021, through June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 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 billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Signatera assay rendered on June 9, 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 are not covered.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that this testing was previously billed under code 81479 by the Plan and paid. Multiple component test results may not be billed. Therefore, we decided that the Plan does not have to pay for the Signatera assay rendered on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says the rules for SNF care have not been met.
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 the beneficiary is an 83-year-old male with falls, congestive heart failure and acute kidney failure. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (G0500) provided November 10, 2020.
You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 G0500 is Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in themonitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older. We find that CPT code G0500 is not supported in the medical record. Specifically, the record does not document the presence of a trained observer. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (G0500) provided November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on February 1, 2021.
You asked the Plan to pay for the services provided. You say that a separate entity may bill diagnostic services. The Plan denied your request. The Plan says when intraoperative neuromonitoring services are reported in a facility, the technical component will be denied.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and the rules. The claim shows a place of service for the monitoring services as an outpatient hospital. Payment for services is made to the hospital. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on April 27, 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 rendered by a non-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only from a network provider.
We looked at the file and the Plan's rules. The file shows that you received hearing aids from a provider not in
the Plan's network. Based on this information, we decided that the Plan's rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on
April 27, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and ground mileage (A0425) provided on March 11, 2021.
You asked the Plan to pay for the ambulance transportation and mileage. You say that you believe these charges should be covered by the Plan because you cannot pay this bill. The Plan denied your request. The Plan says you could have been safely transported by other means of transportation and ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.
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 the ambulance transportation and mileage. Our reviewer says that the documentation does not support that the ambulance transport on March 11, 2021 was medically reasonable and necessary for you. Our physician reviewer found your presenting symptoms did not meet prudent layperson criteria for emergency care. Our reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for you on March 11, 2021. Our physician reviewer also found that the documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on March 11, 2021. 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 ambulance transportation and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and ground mileage (A0425) provided on March 11, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 6, 2021.
You asked the Plan to waive the copayment for the emergency ambulance services. You say that there shouldn't be a copayment for any emergency services. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Medicare covered ambulance services per one-way trip by ground or air. You have been asked to pay a $200 copayment for the emergency ambulance services.
The emergency ambulance services fall within the Ambulance 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 copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 6, 2021.
Your complaint about copayments being applied to emergency services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy rendered on June 23, 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 63047 (laminectomy) and 22633 (single lumbar interspace and segment arthrodesis). Code 63047 is a column II code with a modifier indicator of 1 when billed with column I code 22633. The documentation does not support that code 63047 was billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laminectomy rendered on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning and inspection of removable complete upper denture (D9932), scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921 x 2), and take home drugs (D9630 x 2) provided from August 25, 2021, to September 8, 2021.
You asked the Plan to pay for the dental services. You say that you were advised this provider was in network. You say that a treatment plan was made but the cost for each service was not discussed. You say that you were under the impression that you would be reimbursed for the services. You also say that you feel you were misled. You say that The Plan denied your request.
The Plan says that the cleaning and inspection of removable complete upper denture, scaling in presence of generalized moderate or severe gingival inflammation, gingival irrigation, and take home drugs are not listed as covered services.
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 dental services at issue in this case are not among those covered under this benefit. Additionally, the record shows that you signed a treatment plan which outlines the provider's fee and the amount that the plan would pay for each service. Therefore, we decided that the Plan does not have to pay for the cleaning and inspection of removable complete upper denture (D9932), scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921 x 2), and take home drugs (D9630 x 2) provided from August 25, 2021, to September 8, 2021.
Your complaint about being misled by the representative 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the bifocal lenses (V2200), anti-reflective coating (V2750), and photochromatic tint (V2744), provided October 14, 2021.
You asked the Plan to provide additional payment for the bifocal lenses, anti-reflective coating and photochromatic tint. You say that you disagree with the Plan's denial and would like the lenses covered. The Plan denied your request. The Plan says your full $100 benefit for eyeglasses was applied to this claim and are responsible for the remaining costs.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to a $100 maximum benefit. We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that the $100 benefit for routine eyewear was applied to the claim. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the bifocal lenses (V2200), anti-reflective coating (V2750), and photochromatic tint (V2744), provided October 14, 2021.