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

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on September 24, 2020.You asked the Planto waive the copayment for a CT scan. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for outpatient diagnostic tests/advanced imaging services/freestanding radiological facility. You have been asked to pay a $180 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/advanced imaging services/freestanding radiological facility 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 CT scan provided by a participating provider on September 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pelvic ultrasound rendered on July 20, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe pelvic ultrasound rendered on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from February 10, 2020, to February 18, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were advised that there would not be a copayment.The Plan denied your request. The Plan says the correct copayment was 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 $265 copayment for each day of days 1 to 8 for Medicare-covered hospital care. You have been asked to pay $2,120, or a $265 copayment for each day of days 1 to 8 of your hospital stay for inpatient hospital care. 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 forinpatient hospital care from February 10, 2020, to February 18, 2020.Your complaint aboutreceiving erroneous or ambiguous information about your cost-sharing responsibility from a representative of the provideris 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 13, 2020, 
through September 17, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary for the enrollee. The Plan denied your request. The Plan says that the inpatient 
hospital care was not medically necessary. 
 
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 the 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 that the enrollee presented to the emergency room on September 13, 2020 with 
mental status changes. She was confused; evaluation revealed purulent drainage from both eyes, tachycardia, 
abnormal urinalysis and a white blood cell count increased to 13T. The electrocardiogram demonstrated sinus 
tachycardia and the computed tomography of the brain was negative for any acute ischemic process. She was 
treated with IV fluids, IV antibiotics, antibiotic eye drops and IV Ativan. She was admitted to telemetry, treated 
on the medical floor until medically stable and transferred to an inpatient psychiatric bed on September 17, 
2020. The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from September 13, 2020, through September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue additional payment for the bifocal lenses (V2200), progressive 
lenses (V2781), and the polycarbonate lenses (V2784) provided on October 2, 2020. 
 
You asked the Plan to issue additional payment for these items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says according to your 
contractual policy, the maximum benefit allowance was paid for the vision hardware provided. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.   

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of these items have not been met. Specifically, the Plan contract says that an allowance of 
up to $220 per calendar year is provided for routine vision hardware. Any amount billed by the provider above 
the allowance would be your responsibility. The Plan issued payment for the hardware provided in the amount 
of $220 on October 6, 2020. Therefore, we decided that the Plan does not have to issue additional payment for 
the bifocal lenses (V2200), progressive lenses (V2781), and the polycarbonate lenses (V2784) provided on 
October 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on December 13, 2018.
You asked the Plan to pay for home health services. You say that you submitted the claim timely. The Plan denied your request. The Plan says you did not submit the claim until after the allotted time frame.
The Plan must follow Medicare rules. The rules say that if the claim is not received sixty days after the calculated end date of the episode (day 120) or period (day ninety) or sixty days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by Medicare claims processing systems. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was not submitted until September 16, 2019. The calculated end date of the episode was February 10, 2019, and 120 days from this is June 10, 2019. This is greater than sixty days after the paid date of the RAP on March 3, 2019. Regardless, the claim was not submitted until after either of these two dates; as a result, the claim as submitted on September 16, 2019 was untimely. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on December 13, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrophysiology study. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has no symptoms and has a regular heart rhythm. 
 
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 requested services. Our physician 
reviewer found that the enrollee has asymptomatic, well-rate controlled atrial flutter on anticoagulation. In this 
circumstance of no documented symptoms, no documented congestive heart failure on physical exam, no 
documented poor rate control, and no documented intolerance to anticoagulation, the records do not support the 
medical necessity for an atrial flutter ablation. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrophysiology study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram rendered on September 13, 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 December 1, 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 screening mammogram rendered on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion (96365) provided on June 16, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $180.08 for the Medicare-covered service provided at the outpatient hospital. This is the Plan allowed amount for the service provided, which is less than the appliable copayment. 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 intravenous infusion (96365) provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 2020. 
 
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 billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the ambulatory surgical boot (L3260) 
rendered by the out of network (OON) provider on August 24, 2020. 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not payable as it was rendered by 
an out of network provider. 
 
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 issue reimbursement 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that 
the Plan does not have to issue reimbursement for the ambulatory surgical boot (L3260) rendered by the out of 
network (OON) provider on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided from 
October 21, 2020, through October 23, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $380 
copayment per day, for days 1 through 5 for covered hospital care. Thereafter, you pay a $0 copayment for 
additional Medicare-covered days during your hospital admission.  
 
You have been asked to pay $760 ($380 copayment x 2 days) for the inpatient hospital care provided. 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 adjust the copayment for the inpatient hospital care provided from October 21, 2020, 
through October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by 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 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 medical services provided on August 11, 2020
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because 
most in-network labs are not able to perform this level of testing. The Plan denied your request. The Plan says 
this care was not approved in compliance with the Plans authorization procedures. 
 
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 medical services provided on September 24, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for specialist services provided by an out-of-
network provider from February 25, 2019 to March 25, 2019. 
 
You asked the Plan to waive the deductible for specialist services. You say that you thought this provider was 
in-network. The Plan denied your request. The Plan says the correct deductible amount 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 $500 
deductible for physician/practitioner services/out-of-network.  
 
You have been asked to pay a $283.10 for specialist services. Specialist services fall within the 
physician/practitioner services/out-of-network benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
deductible for specialist services provided by an out-of-network provider from February 25, 2019, to March 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravitreal injection provided on December 11, 2019 
billed with code 67028. 
 
You asked the Plan to pay for the intravitreal injection. You say that you feel that codes 92226 and 67028 are 
payable as billed. The Plan denied your request. The Plan says code 92226 was approved for payment; 
however, 67028 and the other codes were correctly denied as duplicates. 
 
The Plan must follow Medicare rules. Medicare rules say that Column 2 codes are only separately payable with 
Column 1 codes when the modifier indicator is 1, and there is an appropriate NCCI modifier used. 
 
In this case, code 67028 is a Column 2 code in relation to 65800, which was paid on a previous claim. No 
NCCI modifier was reported to justify separate payment. Therefore, we decided that the Plan does not have to 
pay for the intravitreal injection provided on December 11, 2019 billed with code 67028.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for the oral exam (D0120) and prophylaxis (D1110) provided on 
January 6, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you had to pay $50 for the services 
instead of the $20 copayment. You say that you were overcharged for the services. You say that you were 
advised the book keeper would contact you about being overcharged. You say that no one ever contacted you 
to rectify this. You also say that their service was poor. The Plan denied your request. The Plan says that there 
is a $10 copayment for each preventive dental services. The Plan says that the claim processed correctly. 
 
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 dental services were performed by a contract provider. The file does not show that the Plan provided notice 
that the dental services would not be covered. Under Medicare rules, this means the dental services is 
considered approved by the Plan. Therefore, we decided that the Plan has to reimburse you for the oral exam 
(D0120) and prophylaxis (D1110) provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for physician office visits provided to the enrollee from June 10, 2020, to July 8, 2020.
You asked the Plan to pay these services. You say that you are eligible to accept Medicare payment as an out of network provider and these services should be covered by the Plan. The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federal healthcare programs. Maximus upheld the Plans denial. After additional review of several cases from your office, we reopened the appeal.
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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services were met. The Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. Maximus performed a search of the List of Excluded Individuals and/or Entities from the Office of Inspector General and did not find that you were on this list. Without specific documentation from the Plan showing that you were excluded to receive Medicare reimbursement at the time the services were provided, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay for physician office visits provided to the enrollee from June 10, 2020, to July 8, 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.