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

We decided that the Plan does not have to waive the coinsurance for injections performed by a specialist (64633, 99153, 99152, 64634, J2250) provided on January 3, 2019.You asked the Plan to waive the coinsurance for injections. You say that the doctor gave you shots for your neck in your back. You say that the doctor told you he would not charge you.The Plan denied your request. The Plan says physician services with a specialist have a $45 copayment and Medicare Part B prescription drugs have a 20% coinsurance.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 and a 20% coinsurance for physician services and Medicare Part B prescription drugs. You have been asked to pay a $45 copayment and a 20% coinsurance for injections. These servicesfall within the physician services and Medicare Part B prescription drugs benefit category($0.26 x 20% = $0.05 + $45 = $45.05).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 coinsurance for injections performed by a specialist (64633, 99153, 99152, 64634, J2250) provided on January 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided during an Annual Wellness Visit on August 12, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you shouldn't have a copayment because this was an annual wellness visit. The Plan denied your request. The Plan says physician services have a $20 copayment. The Plan also says that all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition.
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 $20 copayment for physician services. You have been asked to pay a $20 copayment for an office visit. This service falls within the physician services benefit category. The record shows that during the annual wellness visit, you were treated for an existing medical condition. 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 office visit (99214) provided during an Annual Wellness Visit on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior instrumentation services coded 22845 provided to the enrollee on April 25, 2019.
You asked the Plan to pay for the anterior instrumentation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 22845 for the anterior instrumentation services has a bundled relationship with code 22853 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anterior instrumentation services coded 22845 provided to the enrollee on April 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) , the crown (D2750) and core buildup (D2950) provided on August 5, 2019.
You asked the Plan to pay for the limited oral evaluation, the crown and core buildup. You say that you were told you had full coverage for dental with no deductible. You say that the office checked your coverage and told you what your policy covered. The Plan denied your request. The Plan says these 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 limited oral evaluation (D0140) , the crown (D2750) and core buildup (D2950) provided on August 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. You asked the Plan to pay for the ambulance services. You say that you did not know that you would be billed for the services since you were not transported. You say that transportation was not necessary because your daughter had arrived on scene and could transport you to your personal doctor instead. You stated that you believe you shouldn't be responsible for the charges since you did not know they would not be covered. The Plan denied your request. The Plan says these services are not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 19, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 17, 2019 to April 19, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford to pay such a high copayment. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay $700 for the inpatient hospital care. $350 per day x 2 = $700. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 17, 2019 to April 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance provided on July 2, 2019.You asked the Plan to pay forperiodontal maintenance. You say that you are covered for preventive dental care. You say that you were advised by the Plan that the cleaning would be covered.The Plan denied your request. The Plan says this 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, periodontal maintenance isnot among those covered under the preventivebenefit.Therefore, we decided that the Plan does not have to pay forperiodontal maintenance provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for injections provided from April 10, 2019 to June 12, 2019. You asked the Plan to reduce the coinsurance for injections. You say that the coinsurance is way higher than it used to be. You say that you cannot afford this coinsurance on your income alone. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The allowed amount for these injections is $7,681.60. The total amount you are being asked to pay is $1,536.32 ($7,681.60 x 20% = $1,536.32). Injections fall within the Medicare Part B prescription drugs 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 reduce the coinsurance for injections provided from April 10, 2019 to June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe injections you received on June 17, 2019.You asked the Plan to waive the cost share forthe services provided. You say that you were positive this was covered under your insurance.The Plan denied your request. The Plan says the cost share was applied based on your plan 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare Part B prescription drugs 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 cost share forthe injections you received on June 17, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services rendered from July 20, 2019 to July 21, 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 that the services were not medically necessary. The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) on July 20, 2019 with chest and epigastric pain. The physical exam was notable for pedal edema. She was admitted to telemetry. The records support that the services were necessary and reasonable to meet the enrollee's needs and to improve and maintain the enrollee's overall health status.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pay for the inpatient hospital services rendered from July 20, 2019 to July 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 10, 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 services were rendered by a non-participating provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on May 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided on September 11, 2019.
You asked the Plan to waive the copayment for outpatient lab work. You say that you feel like this should be billed as preventative. 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 $35 copayment for outpatient diagnostic tests/in-network/labs. You have been asked to pay $14.88 which is less than your copayment amount of $35 for outpatient lab work. The correct copayment has been applied to the service that is in question. Outpatient lab work falls within the outpatient diagnostic tests/in-network/labs 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 outpatient lab work provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 23, 2019 to January 24, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this care was medically necessary.The Plan denied your request. The Plan says the enrollee could have been treated at an observation level of care.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department with chest pain and shortness of breath. His electrocardiogram was concerning with wave changes. The enrollee went to the cardiac catheterization lab. There were no clinical stenosis identified and no acute interventions. After recovery overnight, he was discharged home the following morning. Care provided to the enrollee was observation level. There were no advance interventions or monitoring. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided by "the provider" on July 8, 2019 to July 23, 2019.You asked the Plan to waive the copayment foran emergency room visit. You say that you think these claims have been incorrectly processed.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). Beneficiary's contract with the Plan clearly says that enrollees must pay an $80 copayment for emergency care/in-network/emergency services. The beneficiary has been asked to pay an $80 copayment for each emergency room visit. The total amount you are being asked to pay is $240 ($80 x 3 visits = $240). An emergency room visit falls within the emergency care/in-network/emergency services benefit category. This means that the beneficiary has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the beneficiary agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran emergency room visit provided by the provider on July 8, 2019 to July 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $290 copayment charged for an outpatient nuclear procedure provided on August 13, 2019.You asked the Plan to waive or reduce this copayment. You say that you were told the second procedure would only be $90.The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the Plan contract agreement.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 $290 copayment for outpatient nuclear procedure. 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 or reducethe $290 copayment charged for an outpatient nuclear procedure provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on August 28, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says these 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 rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on August 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you were led to believe that this service was going to be in-network.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on February 11, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by your doctor on February 15, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because you suffered from medical malfeasance. 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for an MRI. An MRI 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 an MRI provided by your doctor on February 15, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 provided on July 29, 2019.You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not eligible for reimbursement.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 for the office visit has a bundled relationship with code 99226 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tetanus vaccine rendered to you on August 22, 2019.You asked the Plan to pay for these services. You say that the claim should be covered.The Plan denied your request. The Plan says the vaccine is not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered to you by Mallory Berry, CNP on August 22, 2019.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.