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

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating provider on September 24, 2019 to December 17, 2019.
You asked the Plan to waive the copayment for podiatry services. You say that you shouldn't be charged for the routine podiatry visits because you have diabetes. The Plan denied your request. The Plan says the correct copayments have 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 $15 copayment for podiatry services/in-network. You have been asked to pay a $15 copayment for podiatry services. The total amount you are being asked to pay is $30 ($15 x 2 visits= $30). The correct copayments have been applied to the services that were provided. Podiatry services fall within the podiatry services/in-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 copayment for podiatry services provided by a participating provider on September 24, 2019 to December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 6, 2020. 
 
You asked the Plan to pay for dental services. You say that you were a provider with the Plan's network as of 
2019. You say that you did not know the insurance had changed to a Medicare plan. The Plan denied your 
request. The Plan says payment cannot be made to a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dental services provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Albuterol provided on February 28, 2020. 
 
You asked the Plan to pay for the Albuterol. You say that you did not receive any self-administered drugs on 
this date. The Plan denied your request. The Plan says Albuterol is a self-administered drug. The Plan also says 
that self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Albuterol provided on 
February 28, 2020.  
 
Benefits for the Albuterol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's complications can be 
handled appropriately in the LTACH level of care. You also say that all of the providers involved in the 
enrollee's case feel that LTACH is the next appropriate level of care for her to succeed. The Plan denied your 
request. The Plan says the requested service does not meet criteria per Medicare Guidelines. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the proposed LTACH that are not already 
available at the current acute care facility. There are no services at the proposed LTACH that the enrollee 
requires that are not already available and covered at the current facility. Our reviewer also found that this 
request for LTACH services will be considered not medically necessary. Continued acute care services at the 
current facility for the time being appears to be most appropriate based on the provided documentation. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on April 17, 2020. 
 
You asked the Plan to pay for the occlusal adjustment (D9951). You say that your tooth is very sensitive and 
it's difficult to eat. You say that you went to the dentist to fix the issue. The Plan denied your request. The Plan 
says the service 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 the 
occlusal adjustment (D9951) provided on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive eye examination (92014) eye refraction 
(92015) and fundus photography (92250) provided March 20, 2019. 
 
You asked the Plan to pay for the vision services. You say that when you called to verify you were told your 
doctors and practice are credentialed. Please review all attached claims. The Plan denied your request. The Plan 
says enrollee's must use an in-network provider for vision services. 
 
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 the services are rendered by an in-network provider. 
 
 
We looked at the file and the Plan's rules. vision services must be provided by an in-network provider. Based 
on this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for Comprehensive eye examination (92014) eye 
refraction (92015) and fundus photography (92250) provided March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and 
fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (CPT 
Code 92310) provided on March 5, 2020 by a non-contracted provider. 
 
You asked the Plan to pay for the contact lens fitting. You say that you are requesting reimbursement of 
services rendered. You state that you spoke with the Plan prior to the appointment to make sure this service 
was covered and you were assured it was. The Plan denied your request. The Plan says they reviewed your 
recorded phone call to the Plan on February 25, 2020 and you did not ask if the Plan would cover a contact lens 
fitting. 
 
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 
coverage of the contact lens fitting have not been met. Review of the file show that you received the contact 
lens fitting on March 5, 2020. This service is not listed in your EOC as a covered benefit. Therefore, we 
decided that the Plan does not have to pay for prescription of optical and physical characteristics of and fitting 
of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (CPT Code 
92310) provided on March 5, 2020 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prescription of optical and physical characteristics of and 
fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia 
(92310), contact lens, pmma, spherical, per lens (V2500) and ophthalmological services: medical examination 
and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more 
visits (92004) provided on February 4, 2020. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 
EOC benefits. 
 
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. The retail price of the conventional contact lenses is $325. A 15% 
discount of $325 would be $48.75. $325 - $48.75 = $276.25 cost after discount. With the reimbursement of 
$119.19, you have received your full maximum benefit of $165 and you are responsible for the any amount 
over the maximum benefit amount. Your EOC states, "Medicare-covered eyewear: $165 Maximum benefit 
every year." Therefore, we decided that the Plan does not have to pay for prescription of optical and physical 
characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, 
except for aphakia (92310), contact lens, pmma, spherical, per lens (V2500) and ophthalmological services: 
medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new 
patient, 1 or more visits (92004) provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), sphere, bifocal, plano to plus or minus 
4.00d, per lens (V2200), vision item or service, miscellaneous (V2799), anti-reflective coating, per lens 
(V2750) and sales tax (S9999) purchased on December 11, 2019 from an out-of-network provider. 
 
You asked the Plan to pay for the eyewear. You say that your 2019 EOC states that eyewear is covered and 
nothing about using an in-network provider. The Plan denied your request. The Plan says you do not have out-
of-network benefits. 
 
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. 
 
Review of the file show that you purchased eyewear on December 11, 2019 from an out-of-network provider. 
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. 
Furthermore, vision item or service, miscellaneous (V2799), anti-reflective coating, per lens (V2750) and sales 
tax (S9999) are not covered. Your EOC states, "covered eyeglasses after cataract surgery includes standard 
frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe 
frames, tinting, progressive lenses or anti-reflective coating)." Therefore, we decided that the Plan does not 
have to pay for frames (V2020), sphere, bifocal, plano to plus or minus 4.00d, per lens (V2200), vision item or 
service, miscellaneous (V2799), anti-reflective coating, per lens (V2750) and sales tax (S9999) purchased on 
December 11, 2019 from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided out of area.
You asked the Plan to pay for the out of area cataract surgery. You say that you knew you would be moving and that your plan would not cover you after a 6 month period of living out of area. You say that you decided to go on to your husband's insurance. You say that you set that service to start on December 31, 2019 but that you then discovered you had coverage with your current plan until January 31, 2020. You say that this denial was caused by a mix up in dates. The Plan denied your request. The Plan says non emergent services provided out of area required prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The records do not show that the services in dispute were emergent in nature. The need for cataract surgery was not unforeseen prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage of the out of area cataract surgery have not been met. Therefore, we decided that the Plan does not have to pay for cataract surgery provided out of area.
MAXIMUS Federal Services read your letter and knows that you may have a question regarding your enrollment in the Plan. MAXIMUS Federal Services cannot answer enrollment questions. MAXIMUS Federal Services is sending a copy of your case file and your letter to the CMS Regional Office, so that it can look into your enrollment question.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dorsal column stimulator (L8679). 
 
You asked the Plan to pre-approve a dorsal column stimulator. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions listed above have been met. 
 
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 a dorsal column stimulator. Our 
reviewer says that the requested stimulator is not medically necessary. Our physician reviewer found the 
patient has rheumatoid arthritis and intractable pain. There is no documentation of adequate conservative 
measures. The diagnosis is not clearly described for the pain. There is no psychological screening. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a dorsal column stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a dorsal column stimulator (L8679).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 3, 2019 to December 5, 2019.

You asked the Plan to pay for the self-administered drugs. You say that you were not capable of going to the pharmacy to obtain the outpatient drug. The Plan denied your request. The Plan says self-administrable drugs are not covered while getting outpatient hospital services.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from December 3, 2019 to December 5, 2019. 

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the six extractions provided on December 9, 2019 by an OON provider.

You asked the Plan to pay for the extractions. You say that you contacted the Plan prior to having these services rendered, and were given a list of in-network providers in your area. You also say that you were not advised that only certain providers at this office were in-network. The Plan denied your request. The Plan says the treating provider is not part of the Plan's network. The Plan also says that the call records do not support that you or the provider's office contacted the Plan to verify if this provider was contracted with your 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the six extractions provided on December 9, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 11, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says care 
received from a non-network provider will not be covered. 
 
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 
laboratory services. 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 laboratory services provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on December 10, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the right and left breast ultrasounds 
provided on January 29, 2020. 
 
You asked the Plan to waive the copayments for the ultrasounds. You say that the ultrasounds were the only 
option for a cancer screening and would like the claim to be processed preventive care. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $100 
copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). For 
this date of service, you have been asked to pay the allowed amount of the claim because this amount is less 
than the $100 copayment for the ultrasounds. 
 
You have been asked to pay a $71.77 copayment for each of the ultrasounds. ($71.77 x 2 = $143.54). The 
ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The medical record shows the reason for the ultrasounds was a breast lump which make the 
ultrasounds diagnostic in nature. 
  
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 right and left breast ultrasounds provided on January 
29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two endosteal implants (D6010 x2), two bone grafts at 
time of implant placements (D6104 x2), and two guided tissue regenerations (D4266 x2) provided on January 
20, 2020. 
 
You asked the Plan to pay for the endosteal implants, bone grafts, and guided tissue regenerations. The Plan 
denied your request. The Plan says these services are not covered benefits under your dental 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 two 
endosteal implants (D6010 x2), two bone grafts at time of implant placements (D6104 x2), and two guided 
tissue regenerations (D4266 x2) provided on January 20, 2020.