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

We decided that the Plan does not have to pay for an office visit (99213) provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized. There were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 an office visit (99213) provided on January 29, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from August 8, 2020 through August 9, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that the
Plan cannot determine if a physician's order was given, how the member came to you, the referring provider,
and/or whether the services are necessary. All providers are required to furnish necessary information to the
health Plan when requested.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for an inpatient
admission provided from August 8, 2020, through August 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sensipar for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says separate payment for this is denied.

The Plan must follow Medicare rules. The rules say that Sensipar cannot be paid for separately from the payment to the ESRD facility. 

This request is not a covered benefit when requested separately. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Sensipar for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received December 23, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee had met their maximum out-of-pocket cost for 2020. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 Ambulance Services. The enrollee was asked to pay a $38.58 copayment for the ambulance transportation. This amount is less than the required copayment of $250 for Ambulance Services. This claim had the enrollee meet the maximum out-
of-pocket costs for 2020. 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 transportation (A0428, A0425) received December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided December 18, 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 this is not a covered service.

The Plan must follow Medicare rules. MI Profile is not listed as a test that has been evaluated and has therefore not met Medicare's criteria for We looked at the file and Medicare rules. 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 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for this equipment to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers 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 durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram routine ECG provided on March 30, 2021.
You asked the Plan to waive the copayment for the electrocardiogram routine ECG. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an electrocardiogram routine ECG on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 per day for Medicare-covered outpatient diagnostic tests.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an electrocardiogram routine ECG on March 30, 2021. You have been asked to pay a $10 copayment for the electrocardiogram routine ECG. The electrocardiogram routine ECG falls within the Outpatient diagnostic 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 the electrocardiogram routine ECG provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the rebase maxillary partial denture (D5720) provided April 5, 2021.

You asked the Plan to pay for the rebase of upper partial denture. You say that you would like the Plan to cover the service. The Plan denied your request. The Plan says you did not call ahead to confirm coverage and this service is not yet eligible for 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 rebase of upper partial denture once every five-year period. 

We looked at, the file and Medicare rules. The Plan provided documentation that a reline of maxillary partial denture was previously covered on September 10, 2019. Based on this information, we decided that the Plan's rules for coverage of the rebase of upper partial denture have not been met. Therefore, we decided that the Plan does not have to pay for the rebase maxillary partial denture (D5720) provided April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the pin retention - per tooth, in addition to restoration (D2951), core buildup, including any pins when required (D2950), and re-cement or re-bond crown (D2920) provided December 14, 2020.

You asked the Plan to provide additional payment for the pin retention, core buildup and re-cement or re-bond crown. You say that you saved money by using your old crown and would like the services covered by the Plan. The Plan denied your request. The Plan says the core-buildup and re-cementing of the crown have been correctly covered with a 50% cost-share. the pin retention is not 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. Your contract with the Plan clearly says that you must pay 50% coinsurance for core buildup and re-cementing a crown that has fallen off.

You have been asked to pay 50% coinsurance for the core buildup and re-cementing your crown. 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 decide the Plan does not have to waive the coinsurance for the core buildup, including any pins when required (D2950), and re-cement or re-bond crown (D2920) provided December 14, 2020. Though the Plan offers a dental benefit in excess of Medicare coverage, the pin retention is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pin retention - per tooth, in addition to restoration (D2951) provided December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 7, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on October 7, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833, L2397) provided March 11, 2021

You asked the Plan to pay for the knee orthosis. You say that the orthosis was medically necessary. The Plan
denied your request. The Plan says insufficient records were provided to support the items billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain sufficient relevant medical records which support medical necessity for the
supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833, L2397) provided March 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 12, 2021 by a non-participating provider.

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 services were rendered by a non-participating provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 12, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiovascular office visit provided on
March 8, 2021.
You asked the Plan to waive the copayment for specialist visit. You say that you went to the office for test
results only and are very unhappy with how you were treated. 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 $40
copayment for specialist visit.
You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the
Physician/Practitioner Services, Including Doctor's Office Visits 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 a cardiovascular office visit provided on March 8, 2021.
Your complaint regarding how you were treated at this visit 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology and lab services (99204, 87088, 87086, 81002) provided on February 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the radiology and lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service
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 radiology and lab services (99204, 87088, 87086, 81002) provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an excision of a benign lesion (D7410) and removal of
an impacted tooth (D7220).

You asked the Plan to pre-approve the excision of a benign lesion and removal of an impacted tooth. You say
that you thought your insurance would help in paying for these services. You also say that you have no extra
money to pay for these services yourself. The Plan denied your request. The Plan says these services are not
covered under your benefit package.

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 pre-approve an
excision of a benign lesion (D7410) and removal of an impacted tooth (D7220).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician. You say that due to a short time period, you were unable to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 11, 2021.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance per visit for radiation therapy.
You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy 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 coinsurance for radiation therapy services provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan on February 25, 2021.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 computed tomography (CT) scan on February 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous infusion provided on October 22, 2020 and the intravenous infusion and golimumab injections provided on November 19, 2020.

You asked the Plan to waive the coinsurance for the intravenous infusions and golimumab injections. You say that you were not told the drug would cost this much or you wouldn't have received the infusion. You say that the treatments didn't work, and you shouldn't have to pay the cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered outpatient hospital visit and 20% coinsurance for Medicare-covered Part B drugs dispensed at a retail pharmacy, mail order pharmacy, physician office, and outpatient facility. 

You have been asked to pay a total of $779.13 for the intravenous infusions and golimumab injections.

The intravenous infusions and golimumab injections fall 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 coinsurance for the intravenous infusion provided on October 22, 2020 and the intravenous infusion and golimumab injections provided on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 15, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. You say that you paid your $20 copayment. 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 $300 copayment for outpatient surgery/in-network. You have been asked to pay $291.49 which is less than your copayment amount of $300 for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network 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 surgery provided by a participating provider on January 15, 2021.