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

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 to the enrollee by an out-of-network provider on January 30, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) scans of the chest, abdomen, and pelvis.

You asked the Plan to pre-approve CT scans. You say that these services are medically necessary. The Plan denied your request. The Plan says that the denial of authorization for these tests is correct, because these CT scans are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

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 CT scans. Our reviewer says that the enrollee meets the Medicare criteria for the requested CT scans. Our physician reviewer found the enrollee is undergoing surveillance for rectal cancer with the last CT scan in December 2020. Per National Comprehensive Cancer Guidelines (NCCN) guidelines, surveillance CT is indicated every 6 to 12 months after treatment. This service is medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) scans of the chest, abdomen, and pelvis.

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: Lab
Decision: Unfavorable

We decided that the Plan has to pay for ColoVantage screening testing provided on October 12, 2020.

You asked the Plan to pay for ColoVantage test. You say that this test was done instead of a colonoscopy and as a result you went in for your first colonoscopy. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is not covered for colorectal cancer screening.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, ColoVantage test, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan has to pay for ColoVantage screening testing provided on October 12, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged to the enrollee for podiatry services provided on June 2, 2020 and July 7, 2020.

You asked the Plan to waive this cost share. You say that you do not believe these charges are correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement. Maximus administratively overturned the Plans decision because medical records were not submitted for review. The Plan requested a reopen and submitted medical records, photos of the enrollee's feet, and photos of the enrollee's insurance card taken at each visit.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $40 copayment for podiatry services. The Plan has provided medical records and pictures to confirm these services were provided. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share charged to the enrollee for podiatry services provided on June 2, 2020 and July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
September 9, 2019.

You asked the Plan to pay for the office visit. You say that the services were provided in good faith and the bill
should be reprocessed at the prevailing rates. The Plan denied your request. The Plan says prior authorization
was required but not obtained.

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 office visit provided by an out-of-network
provider on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and ophthalmic diagnostic imaging provided on January 12, 2021.

You asked the Plan to waive the copayment for the office visit and ophthalmic diagnostic imaging. You say that this was a routine eye exam, and you were charged copayments. The Plan denied your request. The Plan says the copayments 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 specialist physician services and a $110 copayment for Medicare-covered diagnostic radiology services. 

You have been asked to pay a total of $88.53 for the office visit and ophthalmic diagnostic imaging.

Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability

January 12, 2021
Office Visit
$127.08
$45
$45

January 12, 2021
Ophthalmic Imaging
$43.53
$110
$43.53

TOTAL:
$88.53

The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ophthalmic diagnostic imaging 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 the office visit and ophthalmic diagnostic imaging provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography, including CAD when performed; bilateral (77066) provided January 26, 2021.

You asked the Plan to waive the co-payment for the diagnostic radiology services. You say that you had a regular 2-year check-up and had an ultrasound and mammogram which you feel should be covered at 100% due to it being done in preventative measures. The Plan denied your request. The Plan says the claim was processed, and the correct co-payment was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co-payment for Medicare covered diagnostic radiology services for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $50 co-payment for Medicare covered diagnostic radiology services for the diagnostic radiology services. The diagnostic radiology services fall 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 co-payment for the diagnostic mammography, including CAD when performed; bilateral (77066) provided January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug provided on January 23,
2020.

You asked the Plan to pay for the therapeutic parenteral drug. You say that you believe this service should be
covered. The Plan denied your request. The Plan says this service is not covered.

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
therapeutic parenteral drug provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on December 22, 2020.

You asked the Plan to pay for the 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 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 to the enrollee by an out-of-network
provider on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Cloud Massage Shiatsu Foot Massager Machine provided to the enrollee on December 22, 2020.

You asked the Plan to pay for a foot massager. You say that there are no network providers who provide this item. The Plan denied your request. The Plan says amazon.com is not a covered provider, additionally the prescription is dated after the date of purchase.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a Cloud Massage Shiatsu Foot Massager Machine provided to the enrollee on December 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the duplex scan provided on July 17, 2020.

You asked the Plan to waive the deductible for the duplex scan. You say that you only paid a co-payment for
your previous visits. You say that you aren't prepared to pay other expenses. The Plan denied your request. The
Plan says the deductible applied correctly.

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 your deductible is $1,000. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests
and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $1,000 deductible applies to diagnostic radiology services. This cost sharing
is a contractual obligation that had not been met at the time the duplex scan was received on July 17, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the duplex scan provided on July
17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received December 18, 2020.

You asked the Plan to pay for the limited oral evaluation - problem focused. You say that the requested service was necessary to evaluate and determine your treatment options. The Plan denied your request. The Plan says the requested service exceeds the frequency limitation of your benefit.

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 limited oral evaluation - problem focused (D0140) received December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the inpatient hospital services provided from October 23, 2020, to October 27, 2020.

You asked the Plan to adjust the coinsurance for the inpatient hospital services. You say that you should only have 3 days of co-payments due. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 co-payment each day for days 1 to 5 for Inpatient Hospital Care.

You have been asked to pay a $375 co-payment each day for days 1 to 5 for the inpatient hospital services. The inpatient hospital services fall within the Inpatient Hospital Care benefit category. The record shows you were admitted on 8:00 pm October 23, 2020 and discharged 3:00 pm on October 27, 2020. 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 coinsurance for the inpatient hospital services provided from October 23, 2020, to October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 30, 2020.

You asked the Plan to pay for the out-of-network office visit. You say that you do not understand why the claim applied to your deductible. The Plan denied your request. The Plan says you received services from an out-of-network provider hence the claim processed towards your deductible.

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 there is a $1000 deductible for most covered services except from an in-network provider. 

The item or service you asked the Plan to pay for does not fall within the benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for most out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network office visit was received on November 30, 2020. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 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 services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for physician's services for an eye exam provided on November 30, 2020.

You asked the Plan to waive the co-payment for the physician's services for an eye exam. The Plan denied your request. The Plan says the correct co-payment has been applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co-payment for Medicare Covered Vision Services.

You have been asked to pay $50 co-payment for the physician's services for an eye exam. The physician's services for the eye exam falls within the Medicare Covered Vision 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 co-payment for physician's services for an eye exam provided on
November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the "GDC Affordable Care Plan" purchased from your provider.

You asked the Plan to pay for the "GDC Affordable Care Plan". You say that the bundled services were meant to save money. The Plan denied your request. The Plan says the Plan does not provide coverage for the "GDC Affordable Care Plan."

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 "GDC Affordable Care Plan" purchased from your provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided December 26, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were told by the case worker at the clinic that you would have no cost share. 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 $250 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 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 BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided December 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Pride Victory LX Sport four wheel scooter for the
enrollee.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 scooter. Our reviewer says that the
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation
indicates the enrollee has a mobility deficit but does not indicate that this deficit impairs MRADLs in the home
and is not ameliorated by a walker. The documentation does not reveal a detailed upper extremity
neuromuscular exam and the enrollee denies weakness, numbness/tingling on review of systems. The
documentation does not reveal that this scooter would be able to be used in the home. The documentation does
not reveal that the requested power mobility device will significantly improve MRADL participation in the
home.

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 scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Pride Victory LX Sport four wheel scooter for the enrollee.