Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ECG provided on July 13, 2021.  You asked the Plan to waive the copayment for an ECG. You say that you were told the test was needed and you were never told that you would owe a copayment. 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 $5 copayment for outpatient diagnostic tests provided during a primary care provider visit.   You have been asked to pay a $5 copayment for an ECG. An ECG 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 an ECG provided on July 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 30, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that the emergency room misdiagnosed the enrollee multiple times and you feel that he should not be held responsible for any charges related to the incident. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services.   The enrollee has been asked to pay a $200 copayment for ambulance services. Ambulance services 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 ambulance services provided on August 30, 2021.   Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on April 16, 2021.  You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided do not discuss the supplies at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control (L2624) provided to the enrollee on April 15, 2021.  You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that documentation submitted did not sufficiently support the billed supply code.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control (L2624) provided to the enrollee on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services (99292) provided August 27, 2020.  You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.  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 99292 is a critical care visit of an additional 30 minutes of critical care time in addition to the first 30-74 minutes.  We find that CPT code 99292 is not supported in the medical record. Specifically, the records do not show an additional 30 minutes spent on this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99292) provided August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingles vaccine (90750) provided on September 30, 2021.  You asked the Plan to pay for the Shingles vaccine. You say that you believed this drug would be covered under your medical benefit. The Plan denied your request. The Plan says this drug is not covered under the medical benefit is it is considered a Part D drug.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine (90750) provided on September 30, 2021.   Benefits for the Shingles vaccine 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thirty-four (34) additional routine transportation miles.  You asked the Plan to pre-approve the additional routine transportation miles. You say that you are requesting additional mileage. The Plan denied your request. The Plan says you are requesting a total of 84 miles per trip. The Plan states this is 34 miles beyond the maximum distance.  The plan benefits say you have an additional benefit for routine transportation for up to 52 one-way transportation trips per calendar year, limited to ground transportation only to destinations within 50 miles of the pickup location. The benefit states a trip is considered one way, and a round trip is considered two trips. You are requesting a total of 84 miles per trip. Therefore, your request exceeds the miles in your benefit. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve thirty-four (34) additional routine transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99214) provided on July 1, 2021, by an OON provider.  You asked the Plan to pay for a specialist office visit. You say that the patient was seen by the provider due to Parkinson's disease and this is a separate identifiable billable service that was performed out of medical necessity to best treat the patient. You also say this information warrants a reversal of the denial and subsequent payment of the claim. The Plan denied your request. The Plan says that this provider is not a participating Plan provider and there is no prior authorization on file for the member to receive out-of-network care from this provider. The Plan also says that the member was not referred by a participating provider.  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 a specialist office visit (99214) provided on July 1, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 21, 2021.  You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic compression devices have not been met.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.  Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on February 11, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The file shows that CPT code 29876 was billed with code 29880. We find that CPT code 29876 shall not be reported for a major synovectomy with CPT code 29880 knee since knee arthroscopic procedures other than synovectomy are performed in 2 of the 3 knee compartments.  We looked at the file and the rules. We find that CPT code 29877 was billed with code 29880. We find that CPT code 29877. This code pair has a modifier indicator of 0. This means that CPT code 29877 is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs (CPT code E1036).  You asked the Plan to pre-approve the DME. You say that you need this chair because the transfer system enables your caregiver to transfer you from your bed to the chair. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan.  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 DME. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs (CPT code E1036) is not medically necessary per Medicare's LCD: Patient Lifts (L33799) and Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The request appears to exceed your medical need. This item is for a weight capacity over 300lbs and there is no recent weight documented on the medical progress notes. Additionally, the E1036 requires you to need supine positioning for transfers. The documentation does not support details or evidence of a supine need for transfer. You use a Hoyer lift and have been sitting at the edge of the bed in therapy. The documentation does not reveal clear indications of a medical need for supine positioning for transfers.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs (CPT code E1036).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services provided on December 30, 2020.  You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for non-emergent ambulance transportation services provided on July 23, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that the services should be covered since you were admitted to the hospital. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Ambulance services.   You have been asked to pay a $250 copayment for ambulance transportation. There are no Plan guidelines that state ambulance copayments will be waived if the member is admitted. 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 non-emergent ambulance transportation services provided on July 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 28, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 10, 2021.  You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87481, 87491, 87496, 87529, 87591, 87640, 87653, 87661, 87798, 87563, 87641, 87500) provided June 14, 2021.  You asked the Plan to pay for the lab 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.  We find that CPT codes 87481, 87491, 87496, 87529, 87591, 87640, 87653, 87661, 87798, 87563, 87641, and 87500 are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting).   Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87491, 87496, 87529, 87591, 87640, 87653, 87661, 87798, 87563, 87641, 87500) provided June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the office visit, the x-rays, the Part B drugs, and the medical supply provided on March 24, 2021, and April 7, 2021.   You asked the Plan to waive the coinsurance for the office visit, the x-rays, the Part B injections, and the medical supply. You say that you were unaware that the clinic was out-of-network. 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). Your contract with the Plan clearly says that you must pay 50% of the total cost for out-of-network Medicare-covered physician specialist services, 50% of the total cost for out-of-network x-ray services, 50% of the total cost for other out-of-network Medicare Part B drugs, 50% of the total cost for out-of-network Medicare-covered medical supplies.   You have been asked to pay $761.65 for the office visit, the x-rays, the Part B injections, and the medical supply. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-rays and the medical supply fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. The record shows the provider was out-of-network. See chart below.  Date of Service Service Allowed Amount Coinsurance Member Liability March 24, 2021 Office visit $119.99 50% $60.00 April 7, 2021 Methylprednisone injection $3.21 50% $1.61 April 7, 2021 Contrast injection $282.99 50% $141.50 April 7, 2021 Intra-articular hyaluronan injection $800.00 50% $400.00 April 7, 2021 X-ray $158.47 50% $79.24 April 7, 2021 X-ray $158.47 50% $79.24 April 7, 2021 Medical supply $0.11 50% $0.06 Total    $761.65  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 coinsurance for the office visit, the x-rays, the Part B drugs, and the medical supply provided on March 24, 2021, and April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services provided on January 26, 2021.  You asked the Plan to pay for the services provided. You say that in-network benefits should be honored. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the 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.  We looked at the file and the rules. We find that CPT code 97110 is not supported in the medical record. The records show that physical therapy services were provided in a home setting. There is a more comprehensive code to describe the services that were provided on the date of service at issue.   Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on January 26, 2021.