Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/insterspinous stabilization device for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device remains experimental. More research is needed to show safety and efficacy. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/insterspinous stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 the services provided by an out-of-network provider on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for dialysis services you received on April 1, 2021.
You asked the Plan to reduce the coinsurance for the dialysis services. You say that you had previously only paid $56.63 for your dialysis coinsurance. You do not understand why your cost sharing changed. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that as of 2021, the allowed amount for the dialysis services you received is $353.85.
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 dialysis services. You have been asked to pay 20% coinsurance for the dialysis services. The allowed amount for these services is $353.85, and 20% of that amount is $70.77. 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 reduce the coinsurance for dialysis services you received on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on January 18, 2021.
You asked the Plan to pay for the hearing aid. You say that you would have tried another way if you were told in the beginning not to purchase them online. You say that you were told you could use your plan once a year and you want to be reimbursed. The Plan denied your request. The Plan says internet purchases are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan does not pay for hearing aids when they are purchased on the internet.
We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2330, D2331) provided on March 24, 2021.

You asked the Plan to pay for the fillings. You say that you did not know these services were not covered and you cannot afford the bill. The Plan denied your request. The Plan says fillings are not covered by your dental 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 the resin-based fillings (D2330, D2331) provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and a CT scan provided from January 16, 2021, to March 4, 2021.
You asked the Plan to waive the copayments for an inpatient hospital stay and a CT scan. You say that you feel that the charges are too high and nothing was done to help you. 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 $275 copayment for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that you must
pay a $150 copayment for CT scans. You had an inpatient hospital stay from January 16, 2021, to January 17, 2021. Therefore, you are responsible to pay the $275 copayment. You received a CT scan on March 4, 2021. Therefore, you are responsible to pay the total allowed amount of $120.21, which is less than the $150 copayment. The total amount you owe is: $395.21. You have been asked to pay the total copayment amount of $395.21 for an inpatient hospital stay and a CT scan. An inpatient hospital stay falls within the inpatient hospital care benefit category. A 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 copayments for an inpatient hospital stay and a CT scan provided from January 16, 2021, to March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, extraction and anesthesia provided on May 4, 2021.

You asked the Plan to pay for the crown, extraction and anesthesia. You say that the plan only covers metal, but they put a porcelain crown on. The Plan denied your request. The Plan says the 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, 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 crown, extraction and anesthesia provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 14, 2021.

You asked the Plan to waive the copayment for lab work. You say that you did not go to the hospital for the lab work. You say that you went down the hall from the doctor's office. 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 $25 copayment for outpatient diagnostic tests/lab services/outpatient hospital setting.

You have been asked to pay a $25 copayment for lab work. When you see a physician in a hospital-based practice, a hospital location copayment is applied. Lab work falls within the outpatient diagnostic tests/lab services/outpatient hospital setting 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 lab work provided by a participating provider on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 23, 2021.
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that this is the first time you had this procedure and you do not understand the denial. You say that you are asking for payment to be reconsidered. The Plan denied your request. The Plan says the Plan says that procedure code D0150 has a frequency limitation of 1 every 3 plan years.
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, you also have a maximum benefit of one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation provided on January 9, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 23, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for diabetic supplies provided on July 21, 2020.

You asked the Plan to waive the coinsurance for diabetic supplies. You say that the supplies should be covered in full. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for diabetic services and supplies. 

The Plan says you must pay 20% coinsurance for diabetic supplies. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for diabetic supplies. Therefore, we decided that the Plan has to waive the coinsurance for diabetic supplies provided on July 21, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from December 1, 2020, through February 5, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the rendering provider is not allowed to bill for this service.
The Plan must follow Medicare rules. Medicare rules say that a Physical Therapist Assistant is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue is a Physical Therapist Assistant. A
Physical Therapist Assistant is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from December 1, 2020, through
February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hepatobiliary system imaging provided on March 25, 2021.

You asked the Plan to waive the copayment for hepatobiliary system imaging. You say that you were not aware that you would owe anything for testing when you switched to this Plan and cannot afford the charges. 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 $295 copayment for nuclear medicine services for outpatient hospital services.

You have been asked to pay a $295 copayment for hepatobiliary system imaging. Hepatobiliary system imaging falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for hepatobiliary system imaging provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on November 18, 2019.

You asked the Plan to pay for the cleaning. You say that the original claims were sent in electronically on the date of service, and you would like the Plan to reconsider payment. The Plan denied your request. The Plan says these claims were filed untimely and were therefore denied correctly.

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 the cleaning was not filed until January 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Your appeal request contained claim forms with signatures dated on the date of service in question, but there is no evidence that these forms were actually submitted to the Plan on that date or any other follow-up was made regarding payment in the year following services. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 23, 2021 to March 26, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was approved by an admitting physician and was medically necessary. The Plan denied your request. The Plan says that the request for an acute inpatient hospitalization was not medically necessary according to the Plan's criteria.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the enrollee had witnessed seizure like activity, decreased responsiveness and facial droop prior to admission. The record indicates that the physician intended an inpatient admission at the time of initial evaluation. The record provided is sufficient to determine that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights based upon complex medical factors that are documented in the medical record. The elements of the Medicare coverage rules are satisfied. The services are recommended for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 23, 2021 to March 26, 2021.
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 a diagnostic bone marrow biopsy provided on December 4, 2020.
You asked the Plan to waive the copayment for a diagnostic bone marrow biopsy. You say that the biopsy had to be taken again due to an error and you feel that you should not owe the copayment due to the quality of care you received. 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 $195 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received a diagnostic bone marrow biopsy at an outpatient hospital facility on December 4, 2020. Therefore, you are responsible to pay the $195 copayment.
You have been asked to pay a $195 copayment for a diagnostic bone marrow biopsy. A diagnostic bone
marrow biopsy 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
diagnostic bone marrow biopsy provided on December 4, 2020.
Your quality of care 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on March 15, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
June 11, 2020, to June 24, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that you
would not owe a copayment for the stay. 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 $325
copayment for days 1-6 for inpatient hospital care.
You had an inpatient hospital stay from June 11, 2020, to June 24, 2020. Therefore, you are responsible to pay
a $325 copayment for days 1-6 (June 11, 2020, to June 16, 2020). The total amount you owe is: $325
(copayment) x 6 (inpatient days) = $1,950.
You have been asked to pay the total copayment amount of $1,950 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from June 11, 2020, to June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not 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 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 drug testing provided on December 17, 2020 by an out-of-network (OON) provider.