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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on December 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services provided to the enrollee from January 7, 2020 through January 31, 2020.
You asked the Plan to waive the copay for the SNF services. You say that you do not agree with the cost sharing. The Plan denied your request. The Plan says that the enrollee pays a $178 copay per day for days 21-100.
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 $178 copay per day for days 21-100 of SNF care. The enrollee has been asked to pay a $890 copay for the SNF services. The SNF services falls within the days 21-100 of SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services provided to the enrollee from January 7, 2020 through January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing rendered on January 22, 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 claim was not billed correctly.The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes utilizing a next generation sequencing procedure, the procedure must be billed with one CPT code.We looked at the file and Medicare rules. The file show that the provider billed a next generation sequencing procedure with multiple CPT codes. 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 next generation sequencing rendered on January 22, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on October 29, 2018.
You asked the Plan to waive the copayment for the colonoscopy. You say that you expected the colonoscopy to be covered in full. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The record shows that the primary diagnosis code is for a colonoscopy screening and there are no medical records to support that a diagnostic colonoscopy was performed. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided on October 29, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 3, 2020.
You asked the Plan to waive the copayment for lab work. You say that you should not have to pay for this because you have to get the lab work done so often. The Plan denied your request. The Plan says the correct copayment amount 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 $15 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay $4.37 which is less than your copayment amount of $15 for lab work. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye exam and lenses obtained from an out of network provider on March 4, 2020.
You asked the Plan to pre-approve the vision services. You say that you know the provider is out-of-network but their optical office said their patients have been covered by this plan for their services. Please reconsider reimbursing you for the lens. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in-network provider. We looked at the file and the Plan's rules. vision services received from out of network providers are not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve eye exam and lenses obtained from an out of network provider on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a weight management program provided in 2017.
You asked the Plan to pay for a weight management program. You say that you should be reimbursed because you did not exceed the benefit allowance. The Plan denied your request. The Plan says this request was not received timely.
The rules say that Medicare does not cover gym benefits. However, 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 when a reimbursement request is received by the Plan Medicare Preferred by no later than March 31stof the following year. The Plan's rules for coverage of gym benefits have not been met because the request for reimbursement was not received by March 31, 2018 as required by Plan rules. Therefore, we decided that the Plan does not have to pay for a weight management program provided in 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for travel and lodging expenses incurred from September 22, 2019 to November 6, 2019.
You asked the Plan to pay for travel and lodging expenses. You say that you should be considered a transplant patient. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Plans must provide travel and accommodations when a transplant is provided in a distant location. We looked at the file and Medicare rules. The record shows that the travel and lodging at issue was not received in connection to a transplant. Based on this information, we decided that Medicare rules for coverage of travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to pay for travel and lodging expenses incurred from September 22, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation and psychotherapy services provided from September 18, 2019 to November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers available who can provide 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 psychiatric diagnostic evaluation and psychotherapy services provided from September 18, 2019 to November 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics.
You asked the Plan to pay for the foot orthotics. You say that according to your explanation of benefits there is a 40% reimbursement for orthotics. 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 pay for the foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 2, 2020 to February 3, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated in observation.
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 the enrollee presented to emergency department with a one-day history of lightheadedness and altered mental status. In the emergency department, an exam revealed unresponsiveness with a drop arm test. At time of admission, the member reported she was back to her baseline. All imaging was negative and a drug test was positive for opioids which were not administered during her stay. Neurology was consulted and the impression was suspected orthostatic hypotension/dehydration and substance-induced altered mental status. Her condition stabilized and improved and she was discharged home within 24 hours. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.
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 February 2, 2020 to February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory testing and an emergency room
visit provided from January 23, 2020 to January 25, 2020.
You asked the Plan to waive the copayments for lab tests and emergency room visit. You say that you were not
at these providers on these dates. The Plan denied your request. The Plan says the copayment amounts you are
being charged are correct.
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 $10
copayment for lab tests and $90 copayment for emergency care visit. The record shows that these services were
provided to you on these dates of service. Your total copayment obligation is therefore $100.
You have been asked to pay $10 copayment for lab tests and $90 copayment for emergency care visit. Lab tests
and emergency room visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies"
and "Emergency Care" benefit categories. 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 laboratory
testing and an emergency room visit provided from January 23, 2020 to January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided September 23, 2019, October 10, 2019, and November 4, 2019 by an out of area, out of network (OON) provider.
You asked the Plan to pay for these out of area, out of network services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not medically necessary.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these out of area, out of network services have not been met. Therefore, we decided that the Plan does not have to pay for the office visits provided September 23, 2019, October 10, 2019, and November 4, 2019 by an out of area, out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
December 27, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the hospital forced you
to take the ambulance. The Plan denied your request. The Plan says that you pay $275 for Medicare-covered
ambulance services per day.
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 $275
copayment for Medicare-covered ambulance services per day.
You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered ambulance services per day 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 December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received on December 13, 2019.
You asked the Plan to pay for the services. You say that the provider said you would be reimbursed. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received on December 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair transportation services provided January 27, 2020.
You asked the Plan to pay for the wheelchair transportation services. You say that you feel this should be covered because they said it was a liability and it was services provided while at a rehab facility. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the wheelchair transportation services provided January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urological supplies provided on January 24, 2020.
You asked the Plan to pay for the urological supplies. You say that this claim should be paid. The Plan denied
your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient
services.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a
beneficiary.
Records show that the urological supplies were used in a SNF. The facility must furnish all necessary covered
supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies
would have been included in the global payment submitted to the plan by the facility. If the health plan is not
covering the SNF stay, the cost of these supplies is absorbed by the facility. Payment for this claim must be
submitted to the facility for payment, not the health plan. Therefore, we decided that the Plan does not have to
pay for the urological supplies provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 29, 2020.You asked the Plan to pay for the resin-based composite. You say that you believe this service should be covered to prevent further dental issues in the future.The Plan denied your request. The Plan says you were eligible in the Plan's dental coverage as of January 1, 2020. The Plan also says that there was no evidence of prior dental coverage.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, a six month waiting period applies to comprehensive dental services (such as fillings, sealants and extractions) without evidence of continuous prior coverage at time of enrollment in the dental plan. The record shows that you were eligible for your current dental plan as of January 1, 2020, with no evidence of prior dental coverage, and would have needed to wait until after June 1, 2020 to have this service covered by your plan.Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from January 3, 2020 to January 26, 2020.You asked the Plan to waive the coinsurance for dialysis services. You say that in 2019 you did not have any cost-sharing for dialysis, and do not feel that you received proper notification of the change in cost-sharing.The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct.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 dialysis. The allowed amounts of these claims total $4,258.80, resulting in a total coinsurance obligation of $851.76.You have been asked to pay 20% coinsurance for dialysis services. Dialysis services fall within the Services to Treat Kidney Disease 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 dialysis services provided from January 3, 2020 to January 26, 2020.Your complaint regarding not being told about the change in cost-sharing for these services is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery rendered on January 24, 2020.
You asked the Plan to waive the copayment for these services. You say that you have never been charged a copayment for these services. The Plan denied your request. The Plan says the copayment was applied 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 $225 copayment per visit for outpatient surgery or procedure.
Review of the file shows that you received debridement services on January 24, 2020. These services are classified as a surgical procedure on the skin. You have been asked to pay a $225 copayment for these services. These services fall within the outpatient surgery or procedure 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 outpatient surgery rendered on January 24, 2020.