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

We decided that the Plan does not have to pay for the assistant surgeon services rendered.

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 provider type is not covered.

The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS.

We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe iodine concentration supply used during the magnetic resonance imaging (MRI) you had on January 9, 2020.You asked the Plan to waive the coinsurance forthe iodine concentration supply. You say that the copayment for the MRI itself should have included any cost sharing for the iodine concentration.The Plan denied your request. The Plan says you were charged this coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered medical supplies. You have been asked to pay 20% coinsurance for the iodine concentration supply. Your Evidence of Coverage clearly states that chemical agents used during diagnostic procedures are subject to this coinsurance. 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 forthe iodine concentration supply used during the magnetic resonance imaging (MRI) you had on January 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided from June 4, 2020, to June 30, 2020.You asked the Plan to pay forSNF care. You say that this should be covered by Medicare.The Plan denied your request. The Plan says this care was custodial.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the enrollee did not have skilled nursing or therapy needs during the dates at issue. The therapy services she received in the SNF were was discontinued prior tothe dates in question. The enrollee did not require skilled nursing or therapy services on a daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided from June 4, 2020, to June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam with frames and eyeglass lenses provided on September 28, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the eye exam with frames and eyeglass lenses. You say that you would like this claim processed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 they are received from a participating provider. We looked at the file and the Plan's rules. The information we have indicates that these services were received OON from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam with frames and eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam with frames and eyeglass lenses provided on September 28, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for outpatient surgery, drugs, and medical supplies you received.

You asked the Plan to waive the cost sharing for the outpatient surgery, drugs, and medical supplies. You say that you paid your $95 co payment to your doctor and you thought that is all you would have to pay for this surgery. You say that you believe the hospital billed this incorrectly and that you cannot afford this bill.The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that the surgeon is refunding the co payment you paid to him since the co payment is owed to the hospital instead.

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 $95 co payment for outpatient surgery, 20% coinsurance for Part B drugs, and 20% coinsurance for medical supplies. 

Records show that you had an outpatient surgery where you also received Part B drugs and medical supplies. According to your contract with the Plan, the Plan is permitted to charge you separate cost sharing for the Part B drugs and supplies you received during the surgery. You have been asked to pay a $95 co payment for the outpatient surgery, and 20% coinsurance for the drugs and medical supplies you received. 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 sharing for outpatient surgery, drugs, and medical supplies you received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services with CPT code 11055 provided on May 4, 2020.You asked the Plan to pay forCPT code 11055. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit ofservice exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 11055 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT code 11055 have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services with CPT code 11055 provided on May 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on January 10, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you are unhappy with the care the physician provided.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 $40 copayment for a specialist visit. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount basedon 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 fora specialist visit provided on January 10, 2020.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 waive the deductible forseptoplasty provided on February 25, 2020.You asked the Plan to waive the deductible forseptoplasty. You say that you thought that you would only owe a $250 copayment.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. Your contract with the Plan says that there is a $1,000 deductible for out-of-network services. Your contract with the Plan also clearly says that after the $1,000 deductible has been met, enrollee's must pay 35% coinsurance for out-of-network outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.You received a septoplasty on February 25, 2020, with an out-of-network provider. The record shows that you had only paid $425.60 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $574.40. Now that the $1,000 deductible has been met, you are alsoresponsible to pay 35% coinsurance on the difference between the allowed amount and the deductible amount. $1,806.99 (allowed amount) -$574.40 (deductible balance) = $1,232.59 and 35% of that is $431.41. The total amount you owe is: $574.40 + $431.41 = $1,005.81. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followedMedicare rules by clearly disclosing in the contract that there is a $1,000 deductible for out-of-network outpatient surgery and other medical services provided at hospital outpatient facilities andambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time septoplasty was received on February 25, 2020.Therefore, we decided that the Plan does not have to waive the deductible forseptoplasty provided on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe post-stabilization services provided from July 5, 2020 to July 8, 2020.You asked the Plan to pay forthe post-stabilization services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services provided were not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization services. Our reviewer says that the documentation supports that the services rendered were medically reasonable and necessary. Our 
physician reviewer found the documentation shows that the enrollee had evidence of myocardial injury with reduced ejection fraction who received a procedure in the post stabilization (claimed) period. The documentation supports that the care provided was warranted and post stabilization care should be reimbursed due to the evidence of myocardial injury (elevated troponin) and damage (reduced ejection fraction) and the fact that a procedure was performed that was indicated (cardiac catheterization). Therefore, the enrollee met criteria for the services rendered.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 post-stabilization services have been met.Therefore, we decided that the Plan has to pay forthe post-stabilization services provided from July 5, 2020 to July 8, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we willsend you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received.

You asked the Plan to waive the coinsurance for the dialysis services. You say that you have to have this service or your health will decline.  You say that this coinsurance is too expensive for you.The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for dialysis services. 

You have been asked to pay 20% coinsurance for the dialysis 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 coinsurance for dialysis services you received.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on December 23, 
2019. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary for enrollee. The Plan 
denied your request. The Plan says the criteria for coverage were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found the record shows that the enrollee did not 
have skilled nursing or therapy needs. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a primary care provider visit and a 
specialist visit provided on February 5, 2020, and July 22, 2020. 
 
You asked the Plan to waive the copayments for a primary care provider visit and a specialist visit. You say 
that you disagree with the charges because you should not owe a copayment for primary care provider visit. 
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 $15 
copayment for each primary care provider visit and a $30 copayment for each specialist visit. 
 
You had a primary care provider visit on February 5, 2020. Therefore, you are responsible to pay the $15 
copayment.
 
You had a specialist visit on July 22, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
The total amount you owe is: $45.  
 
You have been asked to pay the total copayment amount of $45 for a primary care provider visit and a 
specialist visit. A primary care provider visit and a specialist visit fall within the physician/practitioner services, 
including doctor's office visits 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 copayments for a primary care provider visit and a specialist 
visit provided on February 5, 2020, and July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on June 17, 
2020. 
 
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The 
Plan says that the claim paid at correct benefit level. 
 
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 vision care, Medicare-covered visits.  
 
You have been asked to pay a $35 copayment for the physician's services. The physician's services falls within 
the vision care 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 physician's services 
provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction provided on July 21, 2020. 
 
You asked the Plan to pay for a refraction. The Plan denied your request. The Plan says the refraction was not 
done as a routine vision exam and is not covered when billed as medical under your Health Plan. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for a refraction provided on  
July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from July 8, 2020, to July 9, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the hospital would not allow you to 
take your own medication. You say that this was because of Covid-19. You also say that you were not given 
any choice, that was the rule. The Plan denied your request. The Plan says the drugs that you received are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the self-administered drugs that you received are not covered under 
Medicare Part B. 
 
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 in an outpatient setting from July 8, 2020, to July 9, 2020.  
 
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 porcelain/ceramic crown (D2740) and the core buildup 
(2950) provided on July 22, 2020. 
 
You asked the Plan to pay for the porcelain/ceramic crown and the core buildup. You say that your extra dental 
coverage should provide coverage for the services you received. The Plan denied your request. The Plan says 
these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic crown (D2740) and the core buildup (2950) provided on July 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from July 17, 2020, 
through July 18, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you followed the advice of your 
primary care physician and went to the ER. You say that the claim shouldn't have been denied. The Plan denied 
your request. The Plan says the copayment 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 $50 
copayment for emergency services in an emergency room. 
 
You have been asked to pay a $50 copayment for the ER visit.  
 
Service Standard Copayment Plan Paid Member Liability 
ER Visit $50 $2,008.56 $50 
 
The ER visit falls within the "Emergency care" 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 ER visit provided from July 17, 2020, through July 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (D4260) provide don September 7, 2019, 
and September 14, 2019. 
 
You asked the Plan to pay for osseous surgery. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says the service rendered was 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 osseous 
surgery (D4260) provide don September 7, 2019, and September 14, 2019.