Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), and bitewings - four radiographic images (D0274) provided January 25, 2021, by an OON provider.  You asked the Plan to pay for the dental cleaning, periodic oral exam, intraoral x-ray, and bitewing x-rays. You say that you were unaware that the provider was OON. The Plan denied your request. The Plan says services provided OON are not covered.  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 dental cleaning, periodic oral exam, intraoral x-ray, and bitewing x-rays when you visit a contracted provider to utilize covered dental benefits.  We looked at the file, and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning, periodic oral exam, intraoral x-ray and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), and bitewings - four radiographic images (D0274) provided January 25, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving overall and requires only short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (80053, 83036)
provided on September 22, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be
covered in full as part of your annual wellness visit. 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 $10
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $10 copayment for laboratory services. The record indicates that you received a
Comprehensive Metabolic Panel test and the Hemoglobin, glycosylated (A1C), these are not included in in the
laboratory services that are covered in full. Laboratory services fall within the Outpatient diagnostic tests and
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
laboratory services (80053, 83036) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), periodontal
maintenance (D4910), bitewing x-rays (D0274), and first intraoral periapical x-ray (D0220) provided on
October 6, 2021, by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, periodontal maintenance, bitewing x-rays, and first
intraoral periapical x-ray. You say that this claim was processed incorrectly. You also say that the treating
provider is in-network with the Plan. The Plan denied your request. The Plan says there is no coverage for
services rendered by an OON provider. The Plan also says that you did not contact the Plan prior to this date of
service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation (D0120), periodontal maintenance (D4910), bitewing x-rays (D0274), and first
intraoral periapical x-ray (D0220) provided on October 6, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and two simple extractions (D7140 x2) provided on July 1, 2021.  You asked the Plan to pay for the comprehensive oral evaluation and simple extractions. You say that you were charged for services you did not receive. The Plan denied your request. The Plan says the annual limit allowed by your dental plan has been paid for the 2021 benefit year.  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 Plan offers a $1,500 annual dental benefit maximum. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the July 1, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and two simple extractions (D7140 x2) provided on July 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy services.

You asked the Plan to pre-approve the requested services. You say that early detection of lymphedema is critical to providing the best outcome. The Plan denied your request. The Plan says there is not enough medical evidence to show its efficacy.

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 requested services. Our physician reviewer found that the enrollee has breast cancer. A review of medical literature shows that bioimpedance spectroscopy is allowed for those at risk for lymphedema. A treatment plan that includes radiation, or an axillary or sentinel node biopsy was submitted. Without this information, the requested services are not considered medically reasonable or necessary at this time.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (orthotics).

You asked the Plan to pre-approve diabetic shoes. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (orthotics).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 1, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed a dental exam for a sensitive tooth. You also say that you called the number on the back of your card to get the name of a local dentist who was in-network with your plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that your plan offers a dental plan rider, but you did not enroll in this rider.  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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided
on October 3, 2021.

You asked the Plan to pay for the magnetic resonance angiography. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately
payable.

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, we have confirmed that code 70544
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided on
October 3, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room services provided on August 26, 2020.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rendered services do 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 99285 is Emergency department visit for the evaluation and management of a patient. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record.   The file shows that the enrollee presented to the emergency department after a fall in the parking lot. The records do not indicate the presenting problems were of high severity. 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 emergency room services provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (36415, 80053, 80061, 81001, 82043, 84443, 85025, 87086, 87088, 87186, P9604) provided on September 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for pathology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the services were rendered and referred by non-participating providers. The Plan also says that they have also determined that these services were not urgent or emergent, nor were they approved in advance.  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 pathology services (36415, 80053, 80061, 81001, 82043, 84443, 85025, 87086, 87088, 87186, P9604) provided on September 15, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 22, 2021,
to August 30, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services
that were provided during this time frame do not meet Medicare coverage guidelines as skilled nursing facility
(SNF) level of care.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from August 22, 2021, to August 30, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on September 28, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you did not see a doctor and your family picked you up within an hour. The Plan denied your request. The Plan says you have been charged 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 $90 copayment for each emergency room visit.   The record shows that you were evaluated by the ER staff and placed in triage. Therefore, you have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 emergency room (ER) visit provided on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on April 6, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract
providers at the preferred provider rate when services are not available from preferred providers in the service
area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan
denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on April 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of femoral fracture (27236) provided on
September 4, 2021.
You asked the Plan to pay for the open treatment of femoral fracture. You say that this date of service is after
the termination of the enrollee's Hospice period. You also say that you would like this claim to be reprocessed
for benefits. 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 enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on September 3, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the open treatment of
femoral fracture (27236) provided on September 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the non-emergency transportation; encounter/trip
(T2003) provided on August 7, 2021.
You asked the Plan to reimburse you for the transportation service. You say that you were forced out of the
facility before you were able to make transfers on your own. You say that you are not able to sit upright. You
also say that you had to find your own stretcher transportation. The Plan denied your request. The Plan says the
transportation service is not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when the trip is coordinated through LogistiCare.
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. Specifically, the file shows that
you did not coordinate your transportation with LogistiCare. Therefore, we decided that the Plan does not have
to reimburse you for the non-emergency transportation; encounter/trip (T2003) provided on August 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided by
a participating provider on October 16, 2021.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you were not
treated well. You say that you should not have to pay for this. 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 $200
copayment per admission. You will not pay more than $400 in a calendar year for inpatient mental health care.
You have been asked to pay a $200 copayment per admission for an inpatient mental health stay. The correct
copayment has been applied to the services that were provided. An inpatient mental health stay falls within the
inpatient mental health 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
mental health stay provided by a participating provider on October 16, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit provided on March 17, 2020, and October 22, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that the services were never rendered. The Plan denied your request. The Plan says based on the medical records services were rendered for both dates of service and the proper copayments were 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 $40 copayment for visits to specialists. The total amount of copayment charged was $80 ($40 copayment per visit x 2 visits).
You have been asked to pay a $80 copayment for specialist office visit. specialist office visit falls within the visits to specialists 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 copayments for a specialist office visit provided on March 17, 2020, and October 22, 2020.