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

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 17, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. In addition, the rendering provider and the referring provider are both out of 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 out of network physician services provided to the enrollee on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on
October 16, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 outpatient hospital services provided to the enrollee on October 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on September 23, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you had two procedures on that date of service, so you should only have to pay one copayment. The Plan denied your request. The Plan says you were charged correctly. The Plan says that you had two separate procedures, so two copayments apply because the copayment is owed per-service.

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 $150 copayment for advanced imaging services. 

You have been asked to pay a $150 copayment for the MRI. The MRI falls within the advanced imaging 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 the magnetic resonance imaging (MRI) you had on September 23, 2020.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to waive the copayments for the ER visit and the inpatient hospital services. We decided that the Plan does not have to waive the copayments for the inpatient hospital services.

You asked the Plan to waive the copayments for the ER visit and the inpatient hospital services. You say that if your doctor in Oregon had provided you with proper care, you would not have needed this treatment. You think you should not have to pay these copayments. The Plan says that you were charged these copayments correctly.

We decided that the Plan has to waive the copayment for the ER visit.

We find that the Plan incorrectly charged you a copayment for the ER visit. Your Evidence of Coverage clearly states that if you are admitted to the hospital within 48 hours of our ER visit, then the ER copayment is waived. You were admitted to the hospital within this 48-hour period, so the Plan must waive this copayment.

We also decided that the Plan does not have to waive the copayment for the inpatient hospital services.

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 $395 copayment per day for days 1-4 for the inpatient hospital services. This copayment applies regardless of the reason for the inpatient stay. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the procedure you had to remove seborrheic keratoses at an outpatient hospital facility on October 30, 2020.

You asked the Plan to waive the copayment for the skin lesion removal procedure. You say that you don't understand why the copayment is so high when you have had this procedure in the past with no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($137) is less than your copayment, you are responsible for this full allowed 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 $325 copayment for surgery or other services at an outpatient hospital facility.

You have been asked to pay a $325 copayment for the skin lesion removal procedure. Based on the records provided, this procedure was performed at an outpatient hospital facility. Looking at past claims, other times when you had this procedure, it was performed in a doctor's office. This is based on how your provider bills the place of service. Because date of service October 30, 2020 was billed with an outpatient hospital place of service, the outpatient hospital surgery copayment applies. 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 procedure you had to remove seborrheic keratoses at an outpatient hospital facility on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on February 10, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network services provided to the enrollee on February 10, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the fluorescence in situ hybridization (FISH) testing provided on August 31, 2020.

You asked the Plan to pay for the FISH testing. You say that this was medically necessary and has been paid in the past by the Plan with this diagnosis code. The Plan denied your request. The Plan says that there is a Medicare rule that says that FISH testing due to hematuria is considered screening and is not covered.

Maximus reviewed the rule cited by the Plan in this case. This rule is not controlling for the State of Connecticut, where this testing was performed. The rule's jurisdiction is limited to Kentucky and Ohio.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the FISH testing by a contract provider. The file does not show that the plan provided notice that the FISH testing would not be covered. The rule cited by the Plan cannot be considered notice to the provider of non-coverage as it is not controlling for this jurisdiction. Under Medicare rules, this means the FISH testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the fluorescence in situ hybridization (FISH) testing provided on August 31, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210), and the unspecified
preventive service (D1999) provided on March 4, 2021.

You asked the Plan to pay for the dental services. You say that you have been going to this doctor for more
than 2 years. You say that you have never been charged this amount. You also say that you never received a
notification of the value as you were told that insurance would cover the procedure. The Plan denied your
request. The Plan says complete series x-ray is not listed as a covered service. The Plan says that the
unspecified preventive service is not listed as a covered service either.

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
complete series x-ray (D0210), and the unspecified preventive service (D1999) provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral
periapical x-ray provided on March 9, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that if you received bitewing x-rays it
would have been of your denture, because you only have six bottom teeth. The Plan denied your request. The
Plan says these services are not covered benefits.
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, x-rays other than bitewing x-rays are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
first intraoral periapical x-ray and additional intraoral periapical x-ray provided on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac injection (G0260) provided on February 19, 2021.
You asked the Plan to waive the copayment for an injection. You say that you made sure there would be no cost share. You also say that you called the Plan and was told there would be no charge. The Plan denied your request. The Plan says the copayment 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 a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $200 copayment for a sacroiliac injection. The EOC confirms $200 is the required copayment for this service. A sacroiliac injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 sacroiliac injection (G0260) provided on February 19, 2021.
Your complaint about potentially receiving misinformation from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided on February 23, 2021.

You asked the Plan to pay for an ultrasound. You say that this service was provided in an appropriate place of service. The Plan denied your request. The Plan says this was not billed with the correct POS code.

The Plan must follow Medicare rules. Medicare rules say that a physician furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We looked at the file and Medicare rules. The record shows that the service at issue was provided while the enrollee was an inpatient, but it was reported with the outpatient hospital POS 22. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705) provided on February 23, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for cardiovascular risk factor lab services provided to the enrollee on August 5, 2020.
You asked the Plan to pay for this service. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says that per the Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36139) and (L36523) and (L36129) as well as Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), cardiovascular risk assessment is not covered under the Medicare benefit.
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 Medicare regulations cited by the Plan are not within the MAC B coverage jurisdiction of either the enrollees address or the labs address. This means that those coverage criteria cited by the Plan do not apply. The Plan neglected to provide coverage criteria that is applicable to the appropriate jurisdiction. Therefore, we decided that the Plan has to pay for cardiovascular risk factor lab services provided to the enrollee on August 5, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 15, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you are allowed to use any provider. You also say that you used the same dentist as you did last year, but now your claim is being denied. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective August 5, 2019, to August 5, 2021. The Plan also says that payment cannot be issued for services rendered by a provider who has opted out of Medicare.
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 covered when they are rendered by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 15, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and comprehensive oral evaluation provided on March 25, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays and comprehensive oral evaluation. You say that you found this provider through the Plan, and are supposed to have coverage for annual exams, x-rays, and cleanings. The Plan denied your request. The Plan says the complete series of intraoral x-rays are not covered. The Plan also says that your benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been exceeded.

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, complete series of intraoral x-rays are not among those covered under this benefit. The contract says that comprehensive oral evaluation is limited to one procedure every three years.

The record shows that you received a comprehensive oral evaluation on January 23, 2020, and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays and comprehensive oral evaluation provided on March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from February 10, 2021, to February 12, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you should not be liable for the charges. You also say that it should be covered by the plan. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from February 10, 2021, to February 12, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on January 18, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that last year the Plan covered up to $1,000 for dental work, and this year the amount increased to $1,300. The Plan denied your request. The Plan says services performed by a privately contracted provider are not covered. The Plan also says that you made no attempts to contact the Plan to find a provider that accepts Medicare.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown provided on January 18, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 1, 2020.
You asked the Plan to pay for the dental service. You say that you do not have the funds to pay for this service. You also say that you did not know that this service would not be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 22, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 1, 2020.