Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot go to a skilled nursing facility. You also say that the enrollee has multiple wounds. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been met.
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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that there are not services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-rays provided on October 26, 2020.
You asked the Plan to pay for the additional intraoral x-rays. You say that you go to this office because they accept your plan. You say that they did not let you know the services were exceeded and this is the clinic's responsibility. The Plan denied your request. The Plan says reimbursement has already been issued for one intraoral x-ray.
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 also have a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on October 26, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-rays provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oncology chemotherapy (CPT code(s): J9190, J9263, J0640, J9206).
You asked the Plan to pre-approve the oncology chemotherapy. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says if you want to participate in a Medicare approved clinical research study, you do not need to get approval from the Plan or from your primary care provider. The Plan states whiles you do not need to get the Plan's permission, please tell the Plan before you start participating in a Medicare-approved clinical research study by calling their customer service phone number.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the oncology chemotherapy as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve the oncology chemotherapy (CPT code(s): J9190, J9263, J0640, J9206).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist second opinion to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve a specialist second opinion. You say that you were given a referral to this
facility from your doctor. The Plan denied your request. The Plan says there are in-network providers are
available for these services.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a specialist second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), fluoride varnish (D1206), crown (D2740), and core build up (D2950) provided on June 1, 2021.
You asked the Plan to pay for the dental services. You say that after paying $1,000, you found out that you did not have dental insurance. You say that you called the plan around November 25, 2020, to switch to a different plan. You also say that you feel you should not be responsible for the $1,554 as you have paid your share. The Plan denied your request. The Plan says the periodontal maintenance, fluoride varnish, crown and core build up are not listed as covered services. The Plan says that there is no record that you called to verify your benefits or provider eligibility. The Plan also says there is no record of a call to or from the plan between November 10, 2020, to December 9, 2020.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), fluoride varnish (D1206), crown (D2740), and core build up (D2950) provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve the IRF care. The Plan denied your request. The Plan says this request is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99217) provided March 7, 2021.
You asked the Plan to pay for the observation care. You say that the services were medically necessary. The Plan denied your request. The Plan says the service has a bundled relationship with another service 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, we have confirmed that code 99217 has a Column One/Column Two relationship with code 99218 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for observation care (99217) provided March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 24, 2021.
You asked the Plan to waive the copayment for specialist services. You say that the doctor almost tried to kill you. 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 $30 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $30 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist visit 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 specialist services provided by a participating provider on March 24, 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 pay for the durable medical equipment provided on March 15, 2021.
You asked the Plan to pay for the services provider. You say that the device with the probe is covered by
Medicare and your plan. The Plan denied your request. The Plan says the supplier is not an acceptable provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you receive your care from a provider who is eligible to provide services under Original
Medicare.
The provider at issue in this case is not a network provider with the Plan and is not eligible to provide services
under Original Medicare. 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 durable medical equipment provided on March
15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on June 16, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you used to only pay $12 for the supplies and disagree with the increase in 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 20% coinsurance for DME and related supplies. 

You received DME and related supplies on June 16, 2021. The total allowed amount is $1,751.90 and 20% of that is $350.38.

You have been asked to pay the total coinsurance amount of $350.38 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on June 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided February 3, 2021.

You asked the Plan to pay for the office visit. You say that you submitted the claim for medical care which you
do for all your mental health care. You would like to be paid the allowed amount according to your benefits.
The Plan denied your request. The Plan says the services were rendered by a provider who 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 the outpatient office visit (99214) provided February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on December 3, 2020.
You asked the Plan to pay for the office visit (99202) for the abscessed tooth. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the diagnosis code K04.7, periapical abscess without sinus is not a covered dental diagnosis.
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. There is no indication that services were incident to or an integral part of a covered primary service. Therefore, we decided that the Plan does not have to pay for dental services provided on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility supervision services provided on March 23, 2021, billed with code 99380.

You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your request. The Plan says this code cannot be paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

 CPT code 99380 has a status indicator of "B" in the Physician Fee Schedule. This means that payment is always bundled into other services and cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility supervision services provided on March 23, 2021, billed with code 99380
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Korlym 300mg tablets.

You asked the Plan to pre-approve Korlym. You say that Korlym is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Korlym 300mg tablets.

Benefits for Korlym 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on June 9, 2021.
You asked the Plan to pay for occupational therapy services. You say that the claim was submitted with the corrected diagnosis. You say that the documents show the medical procedures were a necessity and the payment should be reprocessed. The Plan denied your request. The Plan says the diagnosis code was not billed properly.
The Plan must follow Medicare rules. Medicare rules say that CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Specifically, the record shows that this claim was billed with a primary diagnosis of F02.81. Per the ICD-10, this diagnosis code has a code first note, meaning that the underlying condition should be sequenced first. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stent removal provided on May 28, 2021.
You asked the Plan to waive the copayment for these services. You say that this claim should be included as part of your previous procedure. The Plan denied your request. The Plan says that the claim processed 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 $250 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $117.40 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility visit benefit category. This means that you have been asked to pay less than 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 stent removal provided on May 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
December 15, 2020.
You asked the Plan to pay for Ambulance response and treatment, no transport. You say that the ambulance
services should be covered under the Plan due to medical necessity. The Plan denied your request. The Plan
says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable
service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 15, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
provided on December 15, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on December 23, 2020, to April 23, 2021.

You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you have not been billed for these supplies in 2019 and 2020. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for Medicare-approved durable medical equipment items with a purchase cost of $100 or more.

 In this case, the supplier has attested that you have not been charged for your equipment prior to December 2020 due to a billing error which has been corrected. Therefore, you have been asked to pay $20.28, or 20% of the Medicare-allowed charge of $101.42, for the date of service in 2020, and to pay $20.14, or 20% of the Medicare-allowed charge of $100.70, for dates of service in 2021, for an oxygen concentrator. An oxygen

concentrator falls within the "Durable medical equipment (DME) and related 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 coinsurance for an oxygen concentrator provided on December 23, 2020, to April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an ultrasound provided on May 13, 2021.
You asked the Plan to reduce the copayment for an ultrasound. You say that the diagnostic test was performed at an office visit with your primary care provider (PCP). You also say that you thought there would be a $30 copay for diagnostic tests. 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 $155 copayment for radiological diagnostic services, including ultrasounds performed in a physician's office. You have been asked to pay a $102.86, which is less than the $155 copayment for an ultrasound. Ultrasounds 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 reduce the copayment for an ultrasound provided on May 13, 2021.