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

We decided that the Plan does not have to pay for an office visit provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay formorphine (J2274), other drugs (J3490), and delivery (A9901) provided on April 30, 2019.You asked the Plan to pay formorphine, other drugs, and delivery. You say that this was medically necessary.The Plan denied your request. The Plan says sufficient information was not received.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due.We looked at the file and Medicare rules. No medical records were submitted for the date of serviceat issue. Without this information, medical necessity cannot be established. Based on this information, we decided that Medicare rules for coverage of morphine, other drugs, and delivery have not been met.Therefore, we decided that the Plan does not have to pay formorphine (J2274), other drugs (J3490), and delivery (A9901) provided on April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee on September 16, 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 are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 99153 and 99152. These codes have a PC/TC indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forvision care. You say that this provider was recommended by the Plan representative.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on November 14, 2019 by an out of network (OON) provider.Your complaint regarding receiving inaccurate information about the network status of this provider is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for these out-of-network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 April 16, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298) provided by and out-of-network provider on January 7, 2019.You asked the Plan to pay forthe hearing aids. You say that you did not purchase hearing aids from a TruHearing provider due to a sudden hearing loss in your right ear.The Plan denied your request. The Plan says there are network providers available to provide this service.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you see a TruHearing provider. We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the rendering provider and location are not in-network with the Plan and the Plan requires you to see a TruHearing provider for your hearing aid benefit.Therefore, we decided that the Plan does not have to pay forhearing aids (V5298) provided by and out-of-network provider on January 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) treatments for a
non-healing right foot wound.
You asked the Plan to pre-approve the HBOT. You say that the enrollee would benefit from this treatment to
assist in healing of this wound which has not responded to usual wound care measures. The Plan denied your
request. The Plan says HBOT is not covered by Medicare for this condition.
The Plan must follow Medicare rules. Medicare rules say that HBOT may be covered for the above listed
conditions, but is not covered for the treatment of cutaneous, decubitus, or stasis wounds.
In this case, the wound being treated is not a diabetic wound. There is no documentation of any other condition
for which HBOT can be covered. Therefore, we decided that the Plan does not have to pre-approve hyperbaric
oxygen therapy (HBOT) treatments for a non-healing right foot wound.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on November 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on November 12, 2019.You asked the Plan to pay for the first intraoral periapical x-ray. You say that your dentist told you that they needed the x-rays and because the Plan would pay for them. You also say that the x-ray needed to be done because you were in pain and the dentist needed to see what was going on with your tooth.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, dental x-ray(s) are limited to one a year. The record shows that you received a first intraoral periapical x-ray on July 25, 2019 and your dental x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible fora CT scan provided on October 21, 2019.You asked the Plan to waive the deductible fora CT scan. You say that you disagree with the out-of-network charges.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 $750 deductible for out-of-network outpatient diagnostic tests andtherapeutic services and supplies. You received a CT scan from an out-of-network provider on October 21, 2019. Therefore, you are responsible to pay your share of the out-of-network charges. The record shows that you had paid $0 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount of $100.22. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a CT scan was received on October 21, 2019.Therefore, we decided that the Plan does not have to waive the deductible fora CT scan provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on March 25, 2019 through May 29, 2019.
You asked the Plan to pay for the home infusion therapy. You say that this infusion code is not a DME and was not delivered to the member's home. The Plan denied your request. The Plan says S codes are not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT Code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on March 25, 2019 through May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the eye exam provided on October 28,
2019.
You asked the Plan to adjust the copayment for the eye exam. You say that you feel this should be a $20
copayment. The Plan denied your request. The Plan says the services have been processed correctly per 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 $50
copayment for an eye exam to diagnose and treat diseases and conditions of the eye.
Review of the file shows that this eye exam you received on October 28, 2019 included services to diagnosis
and treat diseases of the eye including dilation services. While you do have diabetes, this eye exam included
additional services other than diabetic retinopathy screening. In addition, the file shows that you have an agerelated
cataract and dry eye syndrome of bilateral lacrimal glands.
You have been asked to pay a $50 copayment for the eye exam. The eye exam 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 adjust the copayment for the eye exam provided on
October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam provided on September 5, 2019.You asked the Plan to waive the copayment foran eye exam. You say that this was a routine eye exam and you should not be responsible for the charges.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 enrolleesin 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 $25 copayment for diagnostic eye exams. The medical records show that you received vision services beyond routine vision care on September 5, 2019. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for an eye exam. An eye exam 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 foran eye exam provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided on June 20, 2019 and August 14, 2019.You asked the Plan to waive the copayments forspecialistvisits. You say that you disagree with the charges.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, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialist visit. The medical records show that you received specialist services onJune 20, 2019 and August 14, 2019. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for specialist visits. Specialist visits 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forspecialist visits provided on June 20, 2019 and August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of
coronary calcium.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered service for use in asymptomatic patients.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found there is no evidence of
cardiac signs or symptoms. The requested CT of the heart is not shown to be medically necessary to diagnose,
treat or manage your health.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for irinotecan liposome injections (J9205) provided on July 17, 2019 through July 19, 2019.
You asked the Plan to pay for the injections. You say that you would like reconsideration as this service was medically necessary. The Plan denied your request. The Plan says that the information received is insufficient for claim processing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code J9205 is supported in the record. Specifically, the record clearly indicates that the prescribed dosage was 101mg of this drug and this drug comes in packages with 43mg. The record indicates that 101 unites were billed with 28 discarded. Based on this information, we decided that Medicare rules for coverage of the injections have been met. Therefore, we decided that the Plan has to pay for irinotecan liposome injections (J9205) provided on July 17, 2019 through July 19, 2019.
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 will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction provided on December 11, 2019.You asked the Plan to pay forthe eye refraction. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the eye refraction received is not a covered benefit.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 Original Medicare covered vision services.We looked at the file and the Plan's rules. An eye refraction is not an Original Medicare covered vision service. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay forthe eye refraction provided on December 11, 201
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit provided by provider on December 19, 2019.You asked the Plan to waive the copayment fora specialist office visit. You say that the doctor didn't even come in and say hello to you.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 $50 copaymentfor physician/practitioner services/specialty physician. You have been asked to pay a $50 copayment for a specialist office visit. Since services were provided by a specialist, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialty physician 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 fora specialist office visit provided by provider on December 19, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient surgery services provided out of network. You say that this was a medically appropriate outpatient procedure. You say that you did not believe an authorization was required for a cystoscopy. You say that the enrollee's previous urologist retired and that the enrollee had previously been evaluated in your affiliate emergency room and by a urologist. The Plan denied your request. The Plan says services from non-participating providers are not covered under the enrollee's plan unless they are authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on June 24, 2019.You asked the Plan to waive the coinsurance for the Part B injection. You say that you were not told that if you picked up the injection from the pharmacy it would have been at no cost. You say you cannot afford this cost. 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 20% coinsurance for in-network Medicare Part B covered drugs and chemotherapy drugs. You have been asked to pay $248.64 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,243.20. ($1,243.20 x 20% = $248.64). The Part B injection falls within "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 coinsurance for the Part B injection provided on June 24, 2019.