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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 22,
2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges
because they were taken for an annual wellness exam. 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 $20
copayment for laboratory tests.
You received laboratory tests on January 22, 2020. Laboratory tests are not included in annual wellness visits.
Therefore, you are responsible to pay the $20 copayment.
You have been asked to pay a $20 copayment for laboratory tests. Laboratory tests fall within the outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for laboratory tests provided on January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgery provided on January 22, 2020 and February 26, 2020.
You asked the Plan to waive the copayments for cataract surgery. You say that you were under the impression that you would only owe a $90 copayment per each service. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received cataract surgery on January 22, 2020 and February 26, 2020. Therefore, you are responsible to pay a $325 copayment per each surgery. The total amount you owe is: $650.00. You have been asked to pay the total copayment amount of $650.00 for cataract surgery. Cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery provided on January 22, 2020 and February 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the occupational therapy visits provided
from January 15, 2020 to January 27, 2020.
You asked the Plan to waive the copayments for the occupational therapy visits. You say that these claims are
incorrect. You say your husband did not go to physical therapy from January 15, 2020 to January 27, 2020. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $20 copayment for each visit.
The enrollee has been asked to pay a $20 copayment for each of the occupational therapy visits. ($20 x 3 visits
= $60). The occupational therapy visits fall within the "Outpatient rehabilitation services" benefit category. The
medical record shows the enrollee received occupational therapy services on these dates of service.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayments for the occupational therapy visits provided from
January 15, 2020 to January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital with end-stage renal disease on dialysis and fluid overload. You had a heart attack and were intubated with a breathing tube and feeding tube. You remained on the ventilator and had uncomplicated wound care. You received physical, occupational, and speech therapy in the hospital and need total assistance with functional mobility and activities of daily living. You have skilled nursing needs, but do not require skilled nursing on a daily basis. You have no skilled therapy needs. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services provided on April 16, 2019.
You asked the Plan to waive the copayment for ophthalmology services. You say that you disagree with the charges because you never saw the doctor. 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 $50 copayment for vision care. The medical records show that you received ophthalmology services on April 16, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for ophthalmology services. Ophthalmology services fall 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 ophthalmology services provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the debridement (11042). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 March 17, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 3,
2020 through January 21, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC 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).
Review of the file shows that you were admitted on January 3, 2020 and discharged on January 21, 2020. You
were asked to pay a $225 copayment per day from January 3, 2020 through January 9, 2020, days 1-7 of your
inpatient stay. There were no copayment charges from January 10, 20199, day 8 of your inpatient hospital care
until your day of discharge January 21, 2020. Per your contract there is a $225 copayment per day required for
days 1-7. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for inpatient hospital care from January 3, 2020
through January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prodigy Autocode Glucometer.
You asked the Plan to pre-approve the glucometer. You say that the requested glucometer is medically
necessary. The Plan denied your request. The Plan says the requested brand of glucometer is not a covered
brand.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers.
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 glucometer. Our reviewer says that
The Prodigy Autocode is not medically necessary. Our physician reviewer found while the enrollee may
qualify for a large-print or talking glucometer, there is nothing to explain why the enrollee needs a nonformulary
glucometer, rather than a formulary glucometer.
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 glucometer have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Prodigy Autocode Glucometer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 15, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for GeneSight genetic testing provided on
February 27, 2020.
You asked the Plan to waive the coinsurance for genetic tests. You say that you were told that this testing was
totally covered, and you should not have to pay anything. The Plan denied your request. The Plan says the
coinsurance amount you are being charged is correct.
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 genetic tests. The allowed amount of this claim is $2,815.34, resulting in a coinsurance
obligation of $563.07.
You have been asked to pay 20% coinsurance for genetic tests. Genetic tests fall within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the coinsurance for GeneSight genetic testing provided on February 27, 2020.
Your complaint regarding receiving inaccurate information about the cost-share for these services 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 issue reimbursement for the therapeutic exercises (97110) and the
low-level laser treatment (S8948) provided January 15, 2020 to February 20, 2020.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are
not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) and the low-level laser
treatment (S8948) provided January 15, 2020 to February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (porcelain fused to high noble metal) for teeth
#24 and #25.
You asked the Plan to pre-approve the services. You say that you only have ten of your original teeth. The Plan
denied your request. The Plan says the records indicate that this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a
crown (porcelain fused to high noble metal) for teeth #24 and #25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for vision care provided on March 18, 2020
and March 26, 2020.
You asked the Plan to waive the copayments for vision care. You say that the visits were due to the providers
mistake and you feel that you should not be responsible for the copayments. 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 $30
copayment for exams to diagnose and treat diseases and conditions of the eye by an ophthalmologist.
The medical records show that you received vision care on March 18, 2020 and March 26, 2020. 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 vision care. Vision care 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 copayments for vision care provided on
March 18, 2020 and March 26, 2020.
We note your complaint that the visits were due to the provider's error and unnecessary. Your complaint is a
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about
these types of complaints.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on March 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the coverage rules for this procedure have not been met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The case file sent was largely incomplete. A request for information was submitted on both June 3, 2020 and July 27, 2020 requesting additional information. No additional information was provided by the plan. Therefore, we decided that the Plan has to pay for the ambulance services provided on March 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) and the
mechanical traction therapy (97012) rendered by the out of network (OON) provider on January 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the chiropractic manipulative treatment (98941) and the mechanical traction therapy
(97012) rendered by the out of network (OON) provider on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110 and D5120).
You asked the Plan to pre-approve the dentures. You say that the enrollee's dentures are too large, cause pain,
and fall out. The Plan denied your request. The Plan says these services are covered once per patient per tooth
every sixty months.
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. The Plan covers dentures once
every sixty months.
We looked at the file, and Medicare rules. You need to wait sixty months before receiving this service again.
Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met.
Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110
and D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 26, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services are an extension of the initial visit. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The rendering provider in this case is not a network provider with the Plan. The ordering provider is also not a network provider with the plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the lab services provided on December 4, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on February 8,
2020 through February 21, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says CPT code S9502 has a status indicator of I
which is not valid for Medicare purposes.
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 S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9502 has a status indicator of I. This means that CPT code S9502 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 (S9502)
provided on February 8, 2020 through February 21, 2020.