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

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on October 20, 2020.You asked the Plan to pay forthe dental service. You say that you knew that 2 exams were covered per year. You say that the dentist did not tell you that you would be exceeding your benefit limit. You say that one of the other visits you had was a problem focused exam. You say that you did not know that would count towards your 2 exam limit.The Plan denied your request. The Plan says exams are covered 2 times per calendar year. The Plan says that the frequency limit for exams has been exhausted. The Plan says that you had exams done on January 25, 2020, and July 29, 2020. The Plan also says that the provider verified that you will not be billed for the exam in this case.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 frequency limit for exams has been exceeded. However, the record shows that the provider is not billing you for the denial of this service.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran intrauterine device (IUD) insertion (58300, J7300) provided August 10, 2020.You asked the Plan to pay forthe IUD insertion. You say that the service was medically necessary.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to payforan intrauterine device (IUD) insertion (58300, J7300) provided August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Dulcolax tablets and magnesium citrate (A9270) provided on July 1, 2020.

You asked the Plan to pay for the over-the-counter items. You say that the items should be covered. The Plan denied your request. The Plan says the items were not purchased through the plan-contracted provider and are not eligible for coverage.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that over-the-counter items must be purchased through the plan-contracted supplier. 

The provider in this case is not a network provider with the Plan. Over-The-Counter items obtained from outside suppliers are not eligible for the plan's OTC benefit. Therefore, we decided that the Plan does not have to pay for the Dulcolax tablets and magnesium citrate (A9270) provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2) and alveoloplasty not in conjunction with extractions (D7320).
You asked the Plan to pre-approve the endosteal implants and alveoloplasty. You say that you are having trouble wearing your dentures because of the bone coming out of your gums. You also say that not being able to wear your dentures is impacting your standard of living. The Plan denied your request. The Plan says these services are not covered 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 pre-approve two endosteal implants (D6010 x2) and alveoloplasty not in conjunction with extractions (D7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, core buildup, including any pins when required, periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and two preventive procedures provided from July 2, 2020, to September 3, 2020 by an OON provider.
You asked the Plan to pay for the dental services. You say that this facility is more feasible to your back issue. You also say that this provider is close to your house. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there was no authorization on file for these services.
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 problem focused limited oral evaluation, first intraoral periapical x-ray, core buildup, including any pins when required, periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and two preventive procedures provided from July 2, 2020, to September 3, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroxygen equipment (E1390) provided September 27, 2020.You asked the Plan to waive the coinsurance forthe oxygen equipment. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the oxygen equipment. The oxygen equipment falls within the Durable Medical Equipment 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 coinsurance foroxygen equipment (E1390) provided September 27, 2020
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan does not have to waive or reduce the $1625 copayment charged for inpatient care provided from March 18, 2020 to March 23, 2020.

You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment is a contractual obligation. Maximus partially overturned the Plans decision because the dates of service originally reported by the Plan were incorrect. The Plan requested a reopen and provided records to show you received inpatient care from March 18, 2020 to March 23, 2020. At $325 per day for 5 days the copayment would be $1625.

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). Your contract with the Plan clearly says that you must pay $325 per day for days 1 to 7 of an inpatient stay. 

You had a 5-day inpatient stay. You have been asked to pay $325 per day for the first 5 days. 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 reduce the $1625 copayment charged for inpatient care provided from March 18, 2020 to March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove Formula CG Power Wheelchair (A group 3, heavy duty power wheelchair, defined by code K0862).

You asked the Plan to preapprove a Group 3 power wheelchair. You say that the enrollee requires the device because he cannot use a manual wheelchair anymore.The Plan denied your request. The Plan says Medicare does not cover durable medical equipment (DME) in a skilled nursing facility (SNF) based on statutory definition of DME. Also, the member does not have a qualifying diagnosis for K0862 group 3 power wheelchair.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition;

2. Myopathy; or
3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity 

The rules also say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 3 power wheelchair is being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to preapprove Formula CG Power Wheelchair (A group 3, heavy duty power wheelchair, defined by code K0862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillary partial denture (D5211) provided on August 11, 2020.You asked the Plan to pay forthe maxillary partial denture. You say that you needed this denture because it plays a very critical part in being able to eat and digest food.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in the supplemental dental rider.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 forthe maxillary partial denture (D5211) provided on August 11, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of a residual tooth root (D7250) and local
anesthesia (D9215) provided on August 3, 2020.
You asked the Plan to pay for the dental service. You say that you were not aware that the provider was out of
network. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The
Plan also says that payment cannot be made for services that you receive from 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 who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
removal of a residual tooth root (D7250) and local anesthesia (D9215) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvea referral to a dermatologist for the enrollee.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe information submitted does not show that your doctor cannot care for your condition.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found the lesion on the breast may represent Paget's disease usually associated with breast cancer. It would require a biopsy by a dermatologist.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 referral havebeen met.Therefore, we decided that the Planhas to pre-approvea referral to a dermatologist for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on July 25, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says your plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered under your plan.
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 25, 2020. 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 ambulance services provided on July 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on June 23, 2020.You asked the Plan to waive the copayment forthe ambulance ride. You say that you were told by the hospital that there would be no charge for the ambulance ride. 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 $275 copayment per trip, each way. You have been asked to pay a $275 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 copayment forthe ambulance ride provided on June 23, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan does not have to waive or reduce the 20 % coinsurance ($315.66) charged for outpatient services (observation) provided from December 14, 2019, to December 16, 2019.

You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and your Plan contract agreement. Maximus partially overturned the Plans denial stating  the total allowed amount was $1,012.48 and 20% of that would be $202.50. The Plan requested a reopen and stated that Maximus did not provide the accurate calculations. The Plan states in the reopen that when calculating the Explanation of Benefits, all line items should be considered. The Plan states that the Medicare allowed amount for this service was $1578.30. Twenty percent (20%) of that amount would be $315.66.

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). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient hospital services or outpatient observation services. Review of the Explanation of Benefits and the information submitted by the Plan shows that you were asked to pay the correct amount based on your contract with the Plan and the Medicare allowable rate for these services. 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 reduce the 20 % coinsurance ($315.66) charged for outpatient services provided from December 14, 2019, to December 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you received on
September 28, 2020.
You asked the Plan to waive the copayment. You say that you should have a $0 copayment for this. The Plan
denied your request. The Plan says this was billed as a diagnostic procedure.
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 $225
copayment for outpatient surgery at an outpatient hospital facility.
Review of the file shows that you had a diagnostic colonoscopy on September 28, 2020. You have been asked
to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy you received on
September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe eyeglasses you purchased on September 22, 2020.You asked the Plan to reimburse you forthe eyeglasses. You say that you would like this claim reprocessed and further reimbursement issued.The Plan denied your request. The Plan says the claim has processed correctly and no reimbursement is due.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 with a $200 benefit toward the purchase and fitting of eyeglasses.We looked at the file and the Plan's rules. The file indicates that the eyeglasses were charged at $415 and the member hasa responsibility of $172. This means that you are receiving more than the $200 benefit for the eyeglasses. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe eyeglasses you purchased on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay fordental services (pin retention) provided on July 23, 2020.You asked the Plan to pay forthis service. You say that these dental services should be coveredby the Plan.The Plan denied your request. The Plan says the services provided are not a covered benefit. Maximus overturned the Plans denialbecause they were provided by a Plan contract dentist. The Plan requested are reopen and stated that Maximus did not apply the correct contract criteria. The Plan says that pin retention is not listed as a covered benefit. The Plan states that the provider being a contract dentist is not of issue since enrollees are given prior notice in the Evidence of Coverage that dental services are supplemental and indicate if something is not listed under the dental benefit it is not covered.The Plan is correct in this case. Medicare does not cover dental services. 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, pin retention is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fordental services (pin retention) provided on July 23, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe ultrasound provided on September 1, 2020.You asked the Plan to waive the deductible forthe ultrasound. You say that you were told this would be covered. You say you should not be penalized because you have dense breast tissue. 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. Your contract with the Plan says that there is a $250 deductible that applies towards each Medicare-covered x-ray. The ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category each Medicare-covered x-ray. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards each Medicare-covered x-ray. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on September 1, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthe ultrasound provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe formation of a pedicle (15576) provided on August 3, 2020.You asked the Plan to pay forthe formation of a pedicle. You say that this code is supported.The Plan denied your request. The Plan says this procedure is not documented.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, the CPT Code Manual definition of code 15576 is formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the formation of a pedicle. Our reviewer says that the use of this code is not supported. Our physician reviewer found the operative report did not include documentation of direct or tubed pedicle. There is a more appropriate code for nasolabial flap.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 formation of a pedicle have not been met.Therefore, we decided that the Plan does not have to pay forthe formation of a pedicle (15576) provided on August 3, 2020.