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

We decided that the Plan does not have to waive the copayment for the office visit you had at a heart and vascular specialist's office on May 4, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you only saw a nurse practitioner, not a doctor, on this date. You said that you were seen by her before and never had a copayment. 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 $25 copayment for physician/practitioner services in a specialist's office. You have been asked to pay a $25 copayment for the specialist visit. This copayment applies to both physician and practitioner services. 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 office visit you had at a
heart and vascular specialist's office on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on June 18, 2021.
You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you were told that you would only owe a $150 copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received a sacroiliac joint injection at an ambulatory surgical center on June 18, 2021. A sacroiliac joint injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $301.54, which is less than the $400 copayment.
You have been asked to pay $301.54 for a sacroiliac joint injection. A sacroiliac joint injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for durable medical equipment (DME) provided on May 12, 2021.
You asked the Plan to waive the deductible and coinsurance for DME. You say that the device did not help and you feel that the charges are too high. 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. Your contract with the Plan says that there is a $300 deductible. Your contract with the Plan also clearly says that after the $300 deductible has been met, enrollee's must pay 20% coinsurance for DME and related supplies. You received DME on May 12, 2021. The record shows that you had paid $37.15 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible amount of $262.85. Now that the $300 deductible has been met, you are also responsible to pay 20% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $895 (allowed
amount) - $262.85 (deductible amount) = $632.15 and 20% of that is $126.43. The total amount you owe for DME is: $389.28. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for DME and related supplies which applies to DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME was received on May 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for durable medical equipment (DME) provided on May 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
February 3, 2021, to March 4, 2021.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says the location was not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered. The
location where services were provided must always be reported along with the first visit reported on the claim.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, while a Q
code was billed on this claim, it was not billed on the same date as the first visit. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from February 3, 2021, to
March 4, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 7, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges
because this was a colonoscopy screening. 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 $325
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The medical records show that you had polyps removed during a colonoscopy on May 7, 2021. Therefore, the
colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $325 copayment.
You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient
surgery including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of the torus mandibularis (D7473) provided on June 18, 2021.
You asked the Plan to pay for the dental service. You say that you feel this service should be covered. The Plan denied your request. The Plan says the removal of torus mandibularis is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the the removal of torus mandibularis is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of the torus mandibularis (D7473) provided on June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
March 21, 2021, through March 24, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that based on the documentation leading up to admission, a Myocardial Infarction was ruled out and other findings were a result of the enrollee's more chronic issues. She quickly responded to fluids and antibiotics. There was insufficient evidence for severe infection or other acute condition. Therefore, it was not expected that the enrollee would require hospital services that would likely cross 2 midnight We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 21, 2021, through
March 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on March 11, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 14, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges
because this was your colonoscopy screening. 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 $290
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The medical records show that you had a polyp removed during a colonoscopy provided on June 14, 2021.
Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $290
copayment.
You have been asked to pay a $290 copayment for a colonoscopy. A colonoscopy falls within the outpatient
surgery including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery services provided on March 19, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for oral surgery services. You say that you were unable to locate a network provider who could provide the needed oral surgery services. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for oral surgery services provided on March 19, 2021, by a provider who has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99325) rendered by the
out-of-network (OON) provider on May 25, 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 domiciliary or rest home visit (99325) rendered by the out-of-network (OON)
provider on May 25, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on December 2, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out-of-network physician services provided to the
enrollee on December 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) and prophylaxis (D1110) provided June 22, 2021.
You asked the Plan to pay for the dental services. You say that because of COVID you were not able to get a cleaning all of 2020. Since neither of the allowed cleanings were paid for in 2020, you are requesting that the Plan apply those credits to this medically necessary cleaning. The Plan denied your request. The Plan says this service exceeds the maximum frequency limitation.
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 contract says that one oral exam and one cleaning is allowed every 6 months. The records show that this service was provided on April 13, 2021. 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 periodic oral exam (D0120) and prophylaxis (D1110) provided June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the chest
rendered on December 18, 2020.
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 have been paid.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that one unit of the services at issue have been paid by
the Plan. There is no documentation to support payment of further services. 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 computed tomography angiography (CTA) of the chest rendered on
December 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis, and spine
(77080) provided June 28, 2021.
You asked the Plan to pay for the diagnostic service. You say that this claim denied in error as a duplicate,
however the attached documentation supports that the procedure was performed by this provider. The Plan
denied your request. The Plan says the enrollee's other health Plan has the primary responsibility for this claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the enrollee has another
insurance that is primary. As the secondary insurer, the Plan cannot be held responsible for the diagnostic
service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan
does not have to pay for bone density scan of axial bones like hip, pelvis, and spine (77080) provided June 28,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from May 12, 2021, to May 31, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that this was the patient's second facility stay. You said that if the first facility had treated him adequately, the patient would not have needed the second stay. You stated that you were not anticipating the additional cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services.
Records show that the enrollee was in the first SNF from April 13, 2021, to April 30, 2021, for a total of 18 days. He was not charged a copayment for any day of this stay. The enrollee then went into the second SNF from May 12, 2021, to May 31, 2021, for a total of 20 days. He was not charged a copayment for the first two days of this stay. He was charged a copayment of $184 per day for the remaining 18 days, for a total of $3,312. Please note that the enrollee only had $3,203.09 remaining on his out-of-pocket maximum, so that is all he is being charged. This cost sharing applies regardless of the reason for the stay. 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 skilled nursing facility (SNF) services provided from May 12, 2021, to May 31, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on January 7,
2021 and January 21, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the patient was provided
medically necessary healthcare and the claims were processed incorrectly. You say that the Plan never gave the
provider an out-of-network fee schedule and the underpayment should be resolved. The Plan denied your
request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials
provided on January 7, 2021 and January 21, 2021