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

We decided that the Plan does not have to waive the copayment for the periodic oral evaluation (D0120), bitewing x-rays (D0274) and cleaning (D1110) provided on January 7, 2021 by an out-of-network provider.

You asked the Plan to waive the copayment for the dental services. You say that you feel this bill should have processed with a $0 copay and you are not responsible for this bill. The Plan denied your request. The Plan says these services were received from an out-of-network provider who billed an amount greater than what the Plan allows for services. You are responsible for the difference between what the Plan pays and what the provider bills.

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 $0 copayment for dental cleanings, exams and x-rays. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for charges above what the Plan pays, even for services listed as a $0 copayment. 

You have been asked to pay a total of $95 for the dental services received out-of-network. The provider billed $214 total for the three services, but the Plan's total allowed amount for these services is $119. The Plan paid the full $119, however because this provider is out-of-network, they did not agree to the same negotiated rate that in-network providers agreed to. You are responsible for the difference between the Plan's maximum allowed charge and the amount the out-of-network provider billed ($214- $119 = $95). 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 periodic oral evaluation (D0120), bitewing x-rays (D0274) and cleaning (D1110) provided on January 7, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided November 11, 2020.
You asked the Plan to pre-approve the anesthesia. You say that CPT code 01922-QZ is a covered procedure by regular Medicare. The enrollee was seen by her provider who ordered epidural steroid injection with MAC sedation medically necessary due to fear of injections. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. In this case, diagnosis code M5136 is not listed in Local Coverage Article A57361 as a covered medically necessary diagnosis . Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown or pay more for the endodontic therapy provided on December 23, 2020.
You asked the Plan to pay for the prefabricated post and core and to pay more for the endodontic therapy. You say that you would like to appeal these services. The Plan denied your request. The Plan says your annual maximum benefit had been exhausted.
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 $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the December 3, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown or pay more for the endodontic therapy provided on December 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging and regadenoson injection provided on September 21, 2020.

You asked the Plan to waive the cost for the myocardial perfusion imaging and regadenoson injection. You say that the injection caused severe pain and the IV failed. You say that you don't agree with paying for the coinsurance. The Plan denied your request. The Plan says the cost share 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 $100 copayment for Medicare-covered nuclear medicine at a freestanding provider and 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs. 

You have been asked to pay a total of $142.61 for the myocardial perfusion imaging and regadenoson injection.

The myocardial perfusion imaging falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The regadenoson injection falls within the "Medicare Part B Prescription Drugs" 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 cost for the myocardial perfusion imaging and regadenoson injection provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided December 30, 2020.
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels, except the basic lipid panel. We looked at the file and Medicare rules. This service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that LTACHs do not provide clinical advantage over non-LTACH
acute care hospitals.
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. The patient
is currently undergoing treatment at an acute care hospital (ACH). Initially admitted with acute renal failure,
the enrollee subsequently suffered aspiration pneumonia. The enrollee is not intubated/ventilated. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 4, 2021.
You asked the Plan to pay for the dental service. You say that you have received periodontal maintenance cleaning for years. You also say that you have been told that once you receive this type of cleaning, you have to always receive this type of cleaning. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 periodontal maintenance (D4910) provided on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the total hip arthroplasty (27130) and the physical therapy evaluation (97161) provided on November 5, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 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% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges and a 10% coinsurance for each Medicare-covered physical therapy visit. You have been asked to pay a total of $1,209.85 which includes $1,201.42 ($12,014.24 x 10% coinsurance) for the hip arthroplasty surgery and $8.43 ($84.30 x 10% coinsurance) for the physical therapy evaluation provided. 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 the total hip arthroplasty (27130) and the physical therapy evaluation (97161) provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an elective total knee Arthroplasty with after care to be provided inpatient.
You asked the Plan to provide coverage for an elective total knee Arthroplasty with after care to be provided inpatient. The Plan denied your request. The Plan says that the Plan has approved the elective total knee Arthroplasty to be provided as an ambulatory outpatient procedure. There is no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.
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 an elective total knee Arthroplasty with after care to be provided inpatient. Our reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found that the enrollee is an 81-year-old female with bilateral knee osteoarthritis who was admitted to the hospital for an elective total knee arthroplasty. Medical history and recent clinical notes did not reveal any expectation that the enrollee would require hospitalization that would likely cross 2 midnights to justify inpatient services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an elective total knee Arthroplasty with after care to be provided inpatient have not been met. Therefore, we decided that the Plan does not have to provide coverage for an elective total knee Arthroplasty with after care to be provided inpatient.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer or rearrangement (14301, 14302) provided on June 22, 2020.

You asked the Plan to pay for tissue transfer or rearrangement. You say that these procedures are documented. The Plan denied your request. The Plan says these codes are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 tissue transfer or rearrangement. Our reviewer says that these codes are not supported. Our physician reviewer found CPT Code 14301 is described as adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. CPT 14302 is described as adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof. In this case, the enrollee underwent a mastectomy and underwent immediate reconstruction with implants. The operative report does not indicate that additional incisions were made (i.e. back cuts). The operative report describes an advancement of tissue. A tissue transfer or rearrangement was not performed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer or rearrangement (14301, 14302) provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Inogen oxygen concentrator provided on August 28, 2020.
You asked the Plan to pay for the provided items. You say that the enrollee needs to be reimbursed. The Plan denied your request. The Plan says the enrollee is responsible for the amount.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and the rules. Purchased oxygen equipment is statutorily non-covered. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Inogen oxygen concentrator provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services received on March 3, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the plan is not the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the Billing Department to inform them that a separate plan is the primary insurance in this case. An explanation of benefits from the primary insurance is needed. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for office visit services received on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on March 3, 2020.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home
use (D9630 x2), anterior resin-based composite of two surfaces (D2331), posterior resin-based composite of
two surfaces (D2392), posterior resin-based composite of four or more surfaces (D2394), and two periodontal
scalings and root planings (D4341 x2) provided on December 8, 2020.
You asked the Plan to pay for the drugs or medicaments, resin-based composites, and scalings and planings.
You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says the drugs
or medicaments are not a covered benefit under your dental plan. The Plan also says that your annual maximum
benefit has been exhausted.
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, drugs or medicaments dispensed in the
office for home use (D9630) are not among those covered under this benefit. The Plan also offers a $1,000
annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been
met, you are responsible for the full charges of any additional dental services. The record shows that you met
the annual maximum benefit while processing this claim for the December 8, 2020, date of service and your
annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office
for home use (D9630 x2), anterior resin-based composite of two surfaces (D2331), posterior resin-based
composite of two surfaces (D2392), posterior resin-based composite of four or more surfaces (D2394), and two
periodontal scalings and root planings (D4341 x2) provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 6 and 11, and pontics (D6241) for teeth # 7, 8, 9, and 10.

You asked the Plan to pre-approve the bridge. You say that you would like the bridge to be approved. You say that this is causing you mental distress. You also say that you prefer a bridge over dentures. The Plan denied your request. The Plan says the requested bridge is beyond the scope of 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. The Plan covers the bridge when the services are medically necessary and reasonable.

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 bridge. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the provided documentation indicates that there are missing posterior teeth being treated with the appliance. Therefore, the reviewer found that the requested bridge does not meet the criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 6 and 11, and pontics (D6241) for teeth # 7, 8, 9, and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital clinic visit provided on October 30, 2020.
You asked the Plan to waive the copayment for clinic visit. You say that you were not told ahead of time or at the time of the visit that there would be an additional fee beyond the $35 copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $325 copayment for in-network clinic visit. You have been asked to pay the allowed amount of $140.45, which is less than the $325 copayment for clinic visit. Clinic visit falls within the Outpatient Hospital 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 an outpatient hospital clinic visit provided on October 30, 2020.
Your complaint regarding not being told about the cost-share for this service 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.