Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 6, 2021.
You asked the Plan to pay for an eye refraction. You say that you thought you were having a regular eye examination and the service would be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit since it was a medical vision check.
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. The Plan covers these services when performed by a network provider as part of a routine screening. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, the service at issue is not a covered benefit since it was a medical vision check, and therefore, not covered under the supplemental benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic, prophylactic, or diagnostic injection (96372) injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD on dialysis) 1,000 units (Q5106) provided November 11, 2020 to December 2, 2020.
You asked the Plan to waive the copayment for the injection services. You say that please consider this appeal for the charges assessed for injections you received. You received the same shot every week so why different charges? Since the shots were given in the doctor's office why would there be a $395 copay. The Plan denied your request. The Plan says the claims were processed, and the correct cost share 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare covered Part B drug $395 copayment for Medicare covered surgery or other services provided 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 $433 for the injection services. For 96372 the provider billed $413 for each date of service. Since the allowed amount of $53.85 is less than the copayment amount of $395, you are responsible for the lesser amount of $53.85 for each date of service. For Q5106 the billed amount was $1,440. The allowed amount was $344.48. The 20% coinsurance was applied and therefore you are responsible for $68.90 for each date of service. The injection services fall within the Medicare Part B prescription drugs and Hospital Outpatient facilities and ambulatory surgical center 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 therapeutic, prophylactic, or diagnostic injection (96372) injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD on dialysis) 1,000 units (Q5106) provided November 11, 2020 to December 2, 2020.
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 December 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not urgent or emergent.

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 December 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on December 31, 2020.

You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity for the service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says authorization for out of network services was 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 psychotherapy provided by an out-of-network provider on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive or reduce the cost-share for the resin-based filling, one surface (D2391)
provided for a back tooth on February 8, 2021.
You asked the Plan to waive or reduce the cost-share for the one-surface filling. You say you are confused by
this denial because you only received a consultation on the date in question. You say the work was done four
days later. The Plan denied your request. The Plan says that the filling was processed correctly. White (resinbased
composite) fillings provided on back (posterior) teeth will be processed as silver fillings and you will be
responsible up to the contracted fee. There is also 20% coinsurance required for fillings.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says white fillings for back teeth may be provided once every 24 months, per surface, per
tooth. Multi-surface white fillings on back teeth will be processed as silver fillings and you will be responsible
up to the contracted fee. The contract also states that enrollees must pay 20% for Class 2 Basic Dental Services.
You have been asked to pay $51 for the resin-based filling. The Plan's maximum allowed charge for a onesurface
resin-based filling is $123. This is the full amount that the provider will be paid for this service.
Because the filling was provided for a back tooth, which is rarely seen and would not generally require a white
filling, the Plan processed payment at the rate for a less expensive amalgam (silver) filling. The maximum
allowed charge for a one-surface silver filling is $90. The Plan paid their 80% coinsurance at the cost of the
silver filling. You are responsible for the difference in cost between the resin filling and the silver filling ($123
- $90 = $33), as well as 20% coinsurance for the maximum allowed cost of the silver filling ($90 x 20%
coinsurance = $18), totaling $51 ($33 + $18 = $51).
The contract clearly states that multi-surface white fillings provided for back teeth will be processed at the
amalgam rate. However, the contract does not clearly state that single-surface white fillings will also be
processed at the amalgam rate. The filling you received on the date in question is a one-surface filling, not a
multi-surface filling. This means that the Plan should process this service at the full cost for the resin-based
composite and pay 80% of the full $123 amount. You should be held responsible for 20% coinsurance for the
filling as required in the contract. ($123 x 20% = $24.60). Therefore, we decided that the Plan has to reduce the
cost-share and reprocess the claim for the resin-based filling, one surface (D2391) provided for a back tooth on
February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on March 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that you were not aware you needed a referral. The Plan denied your request. The Plan says this service 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 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 an office visit (99204) provided on March 8, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the complex repair of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet (13132) provided on October 14, 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 $295 copayment for in-network Medicare-covered surgery or other services provided to you at an outpatient hospital, or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $229.52 copayment for the Medicare-covered outpatient surgery provided. This amount is the Plan allowed amount which is less than the applicable copayment for this service. 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 complex repair of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet (13132) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for the psychotherapy (90837) services provided on January 8, 2021 and January 22, 2021.

You asked the Plan to waive the co-payments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payments have been applied correctly to the services provided.

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 $25 for each individual therapy visit via telehealth for Medicare-covered outpatient mental health services.

You have been asked to pay $50 ($25 co-payment x 2) for the individual therapy visits via telehealth for Medicare-covered outpatient mental health 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 co-payments for the psychotherapy (90837) services provided on January 8, 2021 and January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88313, 88305, 88312) provided on August 31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. 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 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 laboratory services (88313, 88305, 88312) provided on August 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided on November 25, 2020, December 9, 2020, and December 23, 2020.
You asked the Plan to waive the copayment for wound care. You say that you are living on a limited income and you thought you were only responsible for a $40 copayment. You say that the patient responsibility should be reduced. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a total of $740 for the wound care.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
November 25, 2020
Wound Care
$293
$295
$293
December 9, 2020
Wound Care
$293
$295
$293
December 23, 2020
Wound Care
$154
$295
$154
TOTAL:
$740
Wound care falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound care is considered a surgical service that was provided by the hospital. 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 wound care provided on November 25, 2020, December 9, 2020, and December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9945) provided on December 18, 2020.
You asked the Plan to pay for an occlusal guard. You say that the item is medically necessary. The Plan denied your request. The Plan says the item at issue is not a covered 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 an occlusal guard (D9945) provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97813 and 97814) provided on August 14, 2020. You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because you were informed that there is a no-visit maximum for acupuncture along with 100% coverage. The Plan denied your request. The Plan says this service was not rendered by a physician.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan requires that acupuncture services be rendered by a physician licensed to provide the service. The record indicates that these services were performed by a licensed acupuncturist and not a physician. Therefore, we decided that the Plan does not have to pay for acupuncture services (97813 and 97814) provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for podiatry services provided on January 28, 2021.

You asked the Plan to waive the co-payment for podiatry services. You say that you disagree with the charges because you are unhappy with the service you received from the provider. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment for podiatry services.

You have been asked to pay a $45 co-payment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided on January 28, 2021.

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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on October 28, 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 psychotherapy services provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care services provided on July 21, 2020, by an in-network provider.

You asked the Plan to waive the copayment for the vision care services. You say that the provider is an ophthalmologist who you go to for eye screenings and cataract treatment. 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 show that you received vision care services provided on July 21, 2020. You were asked to pay a $50 copayment for the services. Your 2020 EOC states that enrollees must pay a $50 copayment for additional diabetic eye exams, and all other Medicare-covered eye exams. 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 vision care services provided on July 21, 2020, by an in-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation services (A0427) provided on August 19, 2020 and August 21, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $350 for Medicare-covered ambulances services per trip.
You have been asked to pay $700 ($350 copayment x 2) for the ambulance trips 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 waive the copayments for the ambulance transportation services (A0427) provided on
August 19, 2020 and August 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 30, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee's diagnosis is not related to hospice, and the trip is not related to hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 30, 2020.