Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met. The QIC overturned the Plans
denial. The Plan requested a reopen and stated the QIC did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator
(E0466RR). The Physician Reviewer determined that the requested ventilator is medically reasonable
and necessary. The Plan argues that the requested ventilator exceeded the enrollee's care needs. The Plan states
that two meta-analyses make it very clear that BiPAP is generally effective for many persons with a
neuromuscular disorder and respiratory fatigue. There was no documentation provided indicating why the
ventilator was necessary instead of a BiPAP. The medical records show the enrollee is a 78-year-old woman
with a diagnosis of amytophic lateral sclerosis (ALS). Given the enrollee's reduced forced vital capacity at
32%, a non-invasive ventilator has been proposed with AVAP PC mode that will target the enrollee's tidal
volume based on ideal body weight. The Plan is correct in this case. LCD L33800 states "products currently
classified as HCPCS code E0465 or E0466 when used to provide CPAP or bi-level PAP (with or without
backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment
category. A ventilator is not eligible for reimbursement for any of the conditions described even though the
ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for
ventilators used to provide CPAP or bi-level CPAP therapy for conditions will be denied as not reasonable and
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive one $20 copayment of the three. Two copayments for $40 should have
been charged for two x-rays of the spine and one x-ray of the upper x-extremity on March 18, 2021.
You asked the Plan to waive these copayments. You say that you do not believe three copayments should be
charged. The Plan denied your request. The Plan says that each copayment was charged based on the claim
submitted by the provider. Maximus upheld the Plans decision. The QIC then reopened the case when an error
was found in the interpretation of the Plan contract.
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 enrollees must pay a $20 copayment for x-rays. The Plan contract also says that
if the same service type is performed at the same session, more than once, only one copayment will be applied.
You had two x-rays of the spine and one x-ray of the upper extremities. Therefore, we have now decided the
Plan should have allowed one $20 copayment for the two x-rays of the spine and a $20 copayment for the x-ray
of the upper extremity to equal $40 instead of $60.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $250 copayment charged, or an upper
gastrointestinal endoscopy provided on March 29, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this procedure qualifies as a
surgery and it was not your fault that it could not be done within the two month timeframe after the procedure
in February. The Plan denied your request. The Plan says this copayment was charged based on the services
billed by your provider and the Plan contract agreement. The QIC overturned the Plans denial administratively
because a Plan contract was not submitted with the case file. The Plan requested a reopen and provided a copy
of the required Plan contract for review.
The Plan is correct in this case. 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 outpatient surgery or outpatient hospital procedures.
We should also note that had this procedure been done within the two-month timeframe noted, you still would
be required to pay this copayment as this procedure was a separate and distinct outpatient procedure which the
Plan also was required to pay a portion of. 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 or reduce the $250 copayment charged, or an
upper gastrointestinal endoscopy provided on March 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for mental health care provided to the enrollee on January 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 Medicare treatment criteria were not met. The QIC overturned the Plans denial. The
Plan requested a reopen and stated that there was no documentation of consultation with the attending or
primary care physician in the enrollee's medical record and no prior authorization for these services.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get prior authorization.
The contract with the Plan says that this type of care requires prior authorization. The provider in this case is
not a network provider with the Plan. The Plan did not pre-approve the service at issue. The provide is not a
Medicare eligible provider based on the medical records. Therefore, we decided that the Plan does not have to
pay for outpatient mental health care provided to the enrollee on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance transport provided to the enrollee on June 18, 2020.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare criteria or ambulance transport were not met. The QIC overturned the Plans
denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria. The Plan says
that the documentation does not specifically support that transport by means other than an ambulance would
not have been appropriate.
The Plan is correct in this case. 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.
The medical records show the enrollee complained of fever; however, none was present. The enrollee
ambulated without assistance to the ambulance. The records show the enrollee was stable with stable vital
signs. The review did not indicate there were health conditions present that would have prevented
transportation by means other than an ambulance. No life support measures were required that could only be
provided during ambulance transport. Medicare coverage criteria were not met. Therefore, we decided that the
Plan does not have to pay for ambulance transport provided to the enrollee on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. The QIC overturned the Plans
denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF services.
The Physician Reviewer determined that the requested IRF care was medically reasonable and
necessary. The Plan argues that you required oxygen at 3 to 5 liters and was desaturating to 83-91% during
therapy and remaining at 91%. Your medical condition did not show that you were able to tolerate 3 hours of
therapy, 5 days a week, or 15 hours of therapy a week.
The Plan is correct in this case, the physical therapy notes specifically stated you were unable to participate in
therapy die to fatigue and shortness of breath while sitting unsupported. The records not you were only able to
tolerate eight minutes of therapy at a time. The documentation did not support that there was a reasonable
expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF (at least 3 hours a day /5 day a week, or 15 hours over 7 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve these dental services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says this benefit is not available. The QIC overturned the Plans
denial. The Plan requested a reopen and provided additional information. The Plan provided conformation that
this service is only covered every three years and had been covered previously for the enrollee on December 1,
2020.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services was not
available for coverage at the time of this request, as it is only covered every three years and had been provided
last in December of 2020. Therefore, we decided that the Plan does not have to pre-approve scaling and root
planing (D4341) for all 4 quadrants for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography scan services provided to the enrollee
on October 27, 2020 and coded as 74261.
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 records required to support the services billed were not submitted by the provider.
The QIC overturned the Plans denial for lack of records submitted. The Plan requested a reopen and confirmed
that they also could not approve payment for this service because the provider did not submit the records
required. The Plan states these records were requested however no response or additional records was received
from the non-contract provider other than the waiver of liability.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when necessary submit the required medical
records to support the services billed. In this case, the required medical records were not submitted to support
payment of this claim. 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 computed tomography scan
services provided to the enrollee on October 27, 2020 and coded as 74261.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay $150 for gym membership for July 1, 2021 to June 30, 2022.
You asked the Plan to pay for gym membership. You believe the Plan owes your fees for July 2021 to July
2022. The Plan denied your request. The Plan says this benefit was already paid. Maximus overturned the Plans
denial. The Plan requested a reopen and provided additional information.
The Plan says that your gym membership renewal date begins July 1 of each year. The proof of payment each
year is for July 1 through June 30 of the following year. You submitted a claim for payment on June 5, 2019
showing proof of payment for July 1, 2018 to June 30, 2019. As this was received after the filing requirement
of March 31st, you were reimbursed $150 toward your 2019 benefit instead of payment for the 2018 benefit as
your claim was not timely.
You submitted a claim on February 24, 2020 for payment of July 1, 2019 to June 30, 2020. Since the Plan had
reimbursed 2019 (due to the 2018 claim being untimely) this claim was processed for the 2020 benefit.
You submitted a claim on Feb 25, 2021 for July 1, 2020 to June 30, 2021, as the Plan had already reimbursed
for 2020, the $150 benefit was applied to 2021.
You submitted a request on July 12, 2021 for gym membership from July 1, 2021 to June 30, 2022. Since you
were already reimbursed for 2021 and 2022 has not begun yet, this request was denied. The Plan states you
would have been eligible for reimbursement for 2022 with the same proof of payment after the calendar year of
2022 begins. The Plan typically is not allowed to reimburse prior to the calendar year beginning.
The Plan is correct in this case. The records show you have been reimbursed for 2019, 2020 and 2021. You
were not paid for 2018 as the claim was untimely and the benefit was forwarded to 2019. The rules say that
Medicare does not cover gym benefits. The Plan offers a benefit that exceeds Medicare coverage. For that
reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only if they are submitted
prior to March 31st. The untimely claim for 2018 caused the Plan to pay forward for this benefit. You have
been paid for 2019, 2020 and 2021. Technically you were asked for payment for 2021/2022, which has not
occurred yet. The Plan's rules for coverage of gym benefits were not met. You would have been eligible to
resubmit this claim in January of 2022.
It should be noted that due to the original Favorable decision on this case, the Plan has sent a notice of
compliance indicating this payment, which is technically for July 1, 2021 to June 30, 2022, was paid to
you under check number 21491152 on September 8, 2021. Therefore, you will not be eligible to submit
this claim again for July 1, 2021 to June 30, 2022 as it has been paid.
When you renew your gym membership on July 1, 2022 to continue to June 30, 2023, that
reimbursement can only be submitted between January 1, 2023 and March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150) and crown - porcelain/ceramic (D2740) provided by an Orthodontist.
You asked the Plan to pre-approve a comprehensive oral exam and crown provided by an Orthodontist. You say that your crown can only be done by a specialist and you do not understand why it isn't covered. The Plan denied your request. The Plan says these services are not covered when provided by an Orthodontist.
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 a comprehensive oral exam and crown provided by an Orthodontist when the services are performed by a participating general dentist. We looked at the file and Medicare rules. In this case the requested services would be performed by an orthodontist. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral exam and crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a
comprehensive oral evaluation - new or established patient (D0150) and crown - porcelain/ceramic (D2740) provided by an Orthodontist.
Your complaint about receiving conflicting information from plan representatives 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81542, 88381) rendered by the out-of-network (OON) provider on July 23, 2021.
You asked the Plan to pay 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 services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81542, 88381) rendered by the out-of-network (OON) provider on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits (99214, G8427, G8950} provided on January 21, 2021 to February 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visits. You say that the cost of the office visits should have been paid in full but the claims were denied. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visits (99214, G8427, G8950} provided on January 21, 2021 to February 4, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on June 7, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan's hearing aid provider are not covered.  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 when provided by the Plan's hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services (99291) provided on April 12, 2021 and April 21, 2021.  You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on April 12, 2021 and April 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 11, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were told by hospital staff that you would not have a cost share for the transfer to the other facility. 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 a $320 copayment for each Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $320 copayment for the ambulance transport. The ambulance transport falls 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 transport provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided July 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral exam and panoramic x-ray. You say that a plan representative gave you the dentist's information. The Plan denied your request. The Plan says these services are not covered when provided OON.
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 comprehensive oral exam and panoramic x-ray when the services are provided in-network. We looked at the file and Medicare rules. In this case the services were provided by an out-of-network
provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided July 16, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation from a plan 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.