Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 3, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not 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 fromout-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on October 19, 2019, core buildup provided on November 27, 2019, and crown provided on December 10, 2019.
You asked the Plan to pay for endodontic therapy, core buildup and crown. You say that you relied on insurance and the dentist to make sure you had appropriate coverage. You say that you assumed you would pay 50% for the procedures. The Plan denied your request. The Plan says the services are not covered because you did not purchase the optional comprehensive dental supplemental 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, 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 endodontic therapy provided on October 19, 2019, core buildup provided on November 27, 2019, and crown provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic phlebotomy (99195) provided on April 30, 
2020. 
 
You asked the Plan to pay for the therapeutic phlebotomy. You say that the copayment should not be assessed 
for the services since these services have been covered previously. The Plan denied your request. The Plan says 
based on Medicare billing criteria, the claim was billed 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 $250 
copayment for outpatient hospital services.  
 
You have been asked to pay $110.73 (the allowed amount) for the therapeutic phlebotomy. A therapeutic 
phlebotomy 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 pay for a 
therapeutic phlebotomy (99195) provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on July 1, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 nurse practitioner services provided on July 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) and needle 
electromyography (EMG) provided on December 9, 2019. 
 
You asked the Plan to pay for the EEG and EMG services. You say that all billed codes are supported. The 
Plan denied your request. The Plan says codes 95955 and 95868 are not supported in the record. 
 
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 coding 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 EEG and EMG services. Our reviewer 
says that the records do not support the billed codes.  
 
 
Our coding reviewer found that documentation did not include EEG during nonintracrainial surgery (i.e. 
carotid endarterectomy or stenting, cardiac surgery); therefore, this code cannot be verified.  For CPT 95868, 
procedure report does not document that needle electromyography was performed on the muscles that are 
innervated by cranial nerves. Therefore, this code cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EEG and EMG services have not been met. Therefore, we decided that the 
Plan does not have to pay for the electroencephalogram (EEG) and needle electromyography (EMG) provided 
on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the wound care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were rendered out-of-network 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 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 medical services provided on June 17, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from June 1, 2020 to June 19, 2020.
You asked the Plan to waive the copayment for these services. You say that you would like the copayment reduced. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20 and a $178 copayment per day for days 21-100 for SNF care.
Review of the file shows that you received 18 days of SNF care from June 1, 2020 to June 19, 2020. You have been asked to pay a $178 copayment per day for these services, for a total of $1,958. These services fall within the SNF care 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 skilled nursing facility (SNF) services rendered from June 1, 2020 to June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist services rendered on April 
30, 2020 and May 21, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the way the 
claims were coded. The Plan denied your request. The Plan says the copayments were 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 $45 
copayment for in-network specialist's office services.  
 
Review of the file shows that you received specialist services on April 30, 2020 and May 21, 2020. Per the 
contract with the Plan, there is a $45 copayment for in-network specialist's office services. This cost sharing is 
a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed 
amount for these services is $21.65. Given that the allowed amount was less than the $45 copayment, you have 
been asked to pay $21.65 per date of service for these services, for a total of $43.30. 
 
Therefore, we decided that the Plan does not have to waive the copayments for the specialist services rendered 
on April 30, 2020 and May 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on March 13, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be 
reconsidered. The Plan denied your request. The Plan says you were charged this cost sharing 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 $395 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $395 for these services. 
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 services (A0429) provided on March 13, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on January 24, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until July 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services rendered on January 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
provided on March 5, 2020. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were told you would not have to pay 
anything at the time of service. 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 $200 
copayment for CT scan.  
 
You have been asked to pay the allowed amount of $112.09, which is less than the $200 copayment for CT 
scan. CT scan falls 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 copayment for a Computed Tomography (CT) scan provided 
on March 5, 2020.  
 
Your complaint regarding receiving inaccurate information 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by a non-
contracted provider. 
 
You asked the Plan to pay for these services. You say that you were told that the services would be covered. 
The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 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 medical services provided 
by a non-contracted provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
6, 2019 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that it is your understanding that 
when a provider is called to see an enrollee during their nursing home stay, the services would be covered by 
Medicare. You also say that if any authorization is needed, the nursing home would be responsible for 
obtaining the authorization. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that the services were not authorized, and the provider did not contact 
the Plan for 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 
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 subsequent nursing facility care provided on 
September 6, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99213) provided on May 20, 2020 by an out of network (OON) provider.You asked the Plan to pay foran OON office visit. You say that this denied in error.The Plan denied your request. The Plan says this was not 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 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 forthe office visit (99213) provided on May 20, 2020 by an out of network (OON) provider.
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 March 
20, 2020. 
 
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 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 out of network services 
provided to the enrollee on March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
30, 2020, through May 12, 2020, by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should only have to 
pay a four (4) day copayment for this facility since three (3) day(s) copayment were paid to another facility. 
The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 shows that you were admitted on April 30, 2020, and discharged on May 12, 2020. You 
were asked to pay a $290 copayment per day from April 30, 2020, through May 6, 2020, days 1-7 of your 
inpatient stay. There were no copayment charges from May 7, 2020, day 8 of your inpatient hospital care until 
your day of discharge May 12, 2020. Per your contract there is a $290 copayment per day required for days 1-
7, per admission. 
 
 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 inpatient hospital care provided from April 30, 2020, 
through May 12, 2020, by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 29, 2019 by an OON 
provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was seeking 
primary care through your providers who are able to provide care for enrollees within a skilled nursing facility. 
The Plan denied your request. The Plan says there was no prior authorization on file. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the medical services provided on May 29, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 30, 2019, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that when a provider is called to see a patient during their nursing home stay, their services would be covered by Medicare and if any authorization is needed the nursing home would be responsible for obtaining the authorization. You state that the nursing home was only provided Medicaid as the patient's insurance and they were not aware that the patient had Medicare until the claim was denied by Medicaid. The Plan denied your request. The Plan says they did not authorize the evaluation services provided to the member.
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 medical services provided on September 30, 2019, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided to the enrollee from September 
19, 2019 to October 19, 2019. 
 
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 Medicare billing criteria were not met. The Plan says that the claim was billed with an 
invalid HIPPS codes for the services billed. The fifth position of the HIPPS code is billed with a value of ?S? for non-
routine supplies (NRS) and no revenue codes 027x with NRS was billed, therefore the Medicare rule for payment of this 
claim were not met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to errors 
regarding the HIPPS codes. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for home health care provided to the enrollee from September 19, 
2019 to October 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on September 29, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. Medicare rules say that services provided while an enrollee is in custody are only covered for the above exceptions. We looked at the file and Medicare rules. The records do not show that you meet one of the exceptions noted above for coverage of the requested services. Services provided while you are in custody are not covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services you received on September 29, 2019.