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

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve consultation visit. You say that it has been your experience that second
opinions within the network are not independent, and you are under the impression that this provider would
render an unbiased opinion. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because this provider is out-of-network with the Plan and you can receive a second opinion
within the Plan network.
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
the medical services to be provided 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 stair lift provided on December 11, 2019.
You asked the Plan to pay for the stair lift. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says this item is never covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the stair lift provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on December 19, 2019.
You asked the Plan to pay for the annual wellness visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed exceed the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
Review of the file shoes that the enrollee had an annual wellness visit on December 19, 2019. The enrollee
previously had an annual wellness visit on February 4, 2019 for which the plan approved and paid. The visit on
December 19, 2019 was less than 12 months from the enrollee's prior annual wellness visit. We looked at the
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual
wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for the annual
wellness visit provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on
September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the unlisted molecular pathology procedure. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 unlisted molecular pathology procedure
provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient visit (CPT 99203) provided on December 3, 2019.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the enrollee was not considered a new patient for this visit.
The Plan must follow Medicare rules. Medicare rules say that Medicare interprets the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. We looked at the file and Medicare rules. The records show that the enrollee was provided E&M services by this provider on October 9, 2018. As the visit in question was provided within 3 years of this visit, the enrollee is not considered a new patient. This means that is inappropriate to bill the visit in question as a new patient visit with CPT code 99203. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for the new patient visit (CPT 99203) provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January
10, 2020 through January 12, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that any treatment received was
needed. You say that the charges should be reconsidered. The Plan denied your request. The Plan says the
copayment 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $345 copayment per day, days 1 to 4 at an in-network inpatient hospital.
The enrollee has been asked to pay a $690 copayment for the inpatient stay. ($345/day x 2 days = $690). The
inpatient stay falls within the "Inpatient hospital 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 copayment for the inpatient stay provided from January 10, 2020 through January 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on March 4, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges due to the care provided. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. The enrollee has been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 copayment for an ER visit provided on March 4, 2020.
We note your complaint about the misdiagnosis and care the enrollee received. Your grievance 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive eyeglass lenses purchased on December 13, 2019
from an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Review of the file show that you purchased the eyewear on December 13, 2019 from an out-of-network
provider. Your EOC states, the Plan provides a $150 allowance once every 24 months for you to use toward the
purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or
contact lens for vision correction. 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 progressive eyeglass lenses
purchased on December 13, 2019 from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee is now mostly contact guard assist
(CGA)-to-supervised for all care. The enrollee has no complex wound care needs, or IV medication
requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a
lesser level of care (including home health care services). SNF care is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on February 10, 2019.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that these are a necessity. You say that you cannot afford this. 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 prosthetic devices and medical supplies. You have been asked to pay a total of $29.72, which is 20% of the allowed amount for the ostomy supplies.
Supply
Allowed Amount
Coinsurance
Member Liability
Ostomy Pouch
$144.40
20%
$28.88
Skin Barrier Powder
$4.23
20%
$0.84
TOTAL:
$29.72
The ostomy supplies fall within the "Prosthetic devices 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 the ostomy supplies provided on February 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and supplies purchased on August 2, 2019.
You asked the Plan to waive the coinsurance for the supplies. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you purchased prosthetic devices and supplies on August 2, 2019. You were reimbursed $61.77 for the ileostomy supplies. Your EOC states, enrollees must pay 20% of the cost for each Medicare-covered prosthetic devices and related supplies. You were assessed less than 20% coinsurance for the total allowed amount of $75.65. 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 prosthetic devices and supplies purchased on August 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 27,
2019 to December 16, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were told there would be a $0
copayment if the stay was under 21 days. You say you cannot afford this copayment. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment per day, days 1 to 20 and a $128 copayment per day, days 21 to 100.
The enrollee has been asked to pay a total of $512 copayment for the SNF stay. The SNF stay falls within the
"Skilled nursing facility (SNF) care" benefit category. The record shows the enrollee had a previous SNF stay
at a different facility from November 22, 2019 to November 27, 2019 which was within the same benefit
period.
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 copayment for the SNF stay provided from November 27,
2019 to December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination provided on December 13, 2019.
You asked the Plan to pay for the radiologic examination. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 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 a radiologic examination provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health care visit
provided on January 15, 2020.
You asked the Plan to waive the copayment for the outpatient mental health visit. You say that you are
appealing this mental health, out-of-network claim. 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 $50
copayment at an out-of-network specialist's office.
You have been asked to pay a $50 copayment for the outpatient mental health visit. The outpatient mental
health visit falls within the "Outpatient mental health care" benefit category. The record shows that the
provider is out-of-network.
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 mental health care visit provided on January
15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the psychiatry visits provided between
February 22, 2019 and August 29, 2019.
You asked the Plan to provide reimbursement for the psychiatry visits. You say that you have not been able to
find a good psychiatrist who accepts Medicare. You feel that the plan should cover the expense of this
provider. The Plan denied your request. The Plan says your Medicare plan cannot make payment for the
services of a provider who has opted out of the program.
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. This
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to provide
reimbursement for the psychiatry visits provided between February 22, 2019 and August 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October
14, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges
because you were told that you would not owe a copayment. 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 a $260
copayment for ambulance services.
You have been asked to pay a $260 copayment for ambulance services. Ambulance services fall within the
ambulance 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 ambulance services
provided on October 14, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services provided to the enrollee on June 24, 2019.
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 that Healthcare Common Procedure Coding System (HCPCS) G0482 (1 Unit) remains 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. In this case, the CPT Code Manual definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found the case file contains a Custom Toxicology Profile for customized screening, an order form, and a Confirmation Results Summary. The documentation in the case file supports the coding of HCPCS G0482 (Drug test(s), definitive; 15-21 drug class(es). 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 services have been met. Therefore, we decided that the Plan has to pay for drug testing services provided to the enrollee on June 24, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided that you provided on November 12, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided that you provided on November 12, 2019.