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

We decided that the Plan does not have to pay for out of network physician services provided from September 15, 2020 to October 6, 2020.
You asked the Plan to pay for out of network services. In your letter directly to Maximus, you stated that you asked the provider if they took the Plan and Medicare coverage and they said they did. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 issue was not whether the provider accepted the Plan and Medicare insurance. The issue is that this provider was not approved by the Plan. We do not show documentation that you contacted the Plan to request this specific provider or had prior authorization.
The Plan had network providers available who could have provided the services at issue in this appeal. Therefore, we decided that the Plan does not have to pay for out of network physician services provided from September 15, 2020 to October 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for telehealth mental health services you received from January 26, 2021, to March 23, 2021.

You asked the Plan to waive the cost sharing for the mental health services. You say that you were told that copayments for telehealth services were waived during the Coronavirus pandemic. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that your annual deductible had not been satisfied prior to these services. The Plan also says that the only Coronavirus-related copayment waiver program they had was for office-based professional services from May 11, 2020, to September 30, 2020. Telehealth services provided in 2021 are still subject to regular cost sharing.

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 10% coinsurance for outpatient mental health services after you meet your $150 annual deductible. 

You have been asked to pay your $150 annual deductible and 10% coinsurance for the mental health services after the deductible was met. 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 telehealth mental health services you received from January 26, 2021, to March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a cervical procedure.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you will not require a greater than two midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient services. Our physician reviewer found that there is no documentation provided to support the expectation the enrollee's care will span two midnights. Therefore, an inpatient stay is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a cervical procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a gastroenterology specialist on August 4, 2020.

You asked the Plan to waive the copayment for the telehealth visit with a specialist. You say that you did not know that a copayment would apply. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for visits with a specialist, including telehealth services. 

You have been asked to pay a $40 copayment for the telehealth visit with a specialist. 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 telehealth visit you had with a gastroenterology specialist on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography provided by a participating provider on February 15, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you do not believe you should have to pay a copayment for this. 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 $25 copayment for outpatient diagnostic tests/ultrasound. You have been asked to pay a $25 copayment for an ultrasound. When additional services are provided during an office visit, additional copayments are applied; therefore, the correct copayment has been applied. An
ultrasound falls within the outpatient diagnostic tests/ultrasound 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 transthoracic echocardiography provided by a participating provider on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital detoxification as of August 21, 2021.

You asked the Plan to pre-approve inpatient hospital care. You say that the enrollee is being actively treated for withdrawal and is on a taper. The Plan denied your request. The Plan says the denial of authorization for continued inpatient hospital care is correct, because this is not medically necessary and the enrollee does not meet inpatient detoxification criteria.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient hospital care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient hospital level of care. Our physician reviewer found it is not expected that the enrollee would improve in a reasonable period of time beyond the date in question as she does not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. Her vitals are stable, and care can be provided at a lower level of care rather than inpatient 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital detoxification as of August 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
January 31, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your son came
home and found you unconscious and unresponsive, so he called 911. You say when the ambulance came to
your home, they applied devices to check your heart rate and you woke up at this point and you were told to
follow up with your doctor. The Plan denied your request. The Plan says the Medicare ambulance benefit is a
transport benefit, and if no transport of a Medicare beneficiary occurs, and then there is no Medicare-covered
service.
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 January 31, 2021. 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 response and treatment, no transport
provided on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the limited oral evaluation and unspecified preventive procedure provided on April 13, 2021 at the in-network rate.

You asked the Plan to pay the in-network rate for the limited oral evaluation and unspecified preventive procedure. You say that you were informed the doctor was a network provider and that the enrollee was eligible for the evaluation. You say that the Plan should reconsider the way the claim was paid. The Plan denied your request. The Plan says the limited oral evaluation was paid based on the out-of-network benefit and the unspecified preventive procedure 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 Plan is only obligated to pay 50% of the cost for the evaluation from an out-of-network provider and the unspecified preventive procedure is not a covered benefit. The records show the claim processed correctly because the dentist is out-of-network. Therefore, we decided that the Plan does not have to pay the in-network rate for the limited oral evaluation and unspecified preventive procedure provided on April 13, 2021 at the in-network rate.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received from January 1, 2021, to January 3, 2021.

You asked the Plan to waive the copayment for the ER services. You say that the ER copayment should be waived because you were admitted to the hospital. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not admitted as an inpatient.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for emergency room services. 

You have been asked to pay a $100 copayment for the ER services. The medical records from this ER visit show that you were not admitted to the hospital as an inpatient. In fact, you signed a notice entitled 'Observation Notice' that states that "you're a hospital outpatient receiving observation services. You are not an inpatient." The records show that you were kept in observation status until your discharge, and you were never formally admitted to the hospital. 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 emergency room (ER) services you received from January 1, 2021, to January 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the outcome of the denied authorization. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you were diagnosed with near-syncope and the estimated length of stay was 1 day according to the notes. Our reviewer also found that the provided records do not support that you
would require hospital care that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network neurosurgeon.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical reason to obtain a second opinion.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network neurosurgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve the gloves. You say that this is medically necessary and should not have been denied. The Plan denied your request. The Plan says these are a hygienic, non-reusable item, and therefore not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the urgent care visit provided on December 5, 2020.
You asked the Plan to pay for the urgent care visit. You say that you do not have other insurance. The Plan denied your request. The Plan says that they are not the primary payer for this claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent the bill to the primary insurer, directed the provider to send the bill to the primary insurer, nor paid for the services and submitted a bill for reimbursement to the primary insurer. Therefore, we decided that the Plan has to pay for the urgent care visit provided on December 5, 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 will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the oncology visits you had from January 27, 2021, through April 28, 2021 and the Retacrit injections you received on January 27, 2021, February 24, 2021, and March 17, 2021.

You asked the Plan to waive the cost sharing for the specialist visits and injections. You say that you do not understand why you are getting multiple copayments for the same dates of service. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for each of the office visits, the allowed amount for each visit ($20.85) is less than your office visit copayment responsibility, so you are responsible for the allowed amount. In addition, the Plan says that for the three visits where you received injections, you were appropriately charge the applicable coinsurance for the drugs you received.

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 $45 copayment for specialist visits and 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $45 copayment for each the specialist visits and 20% coinsurance for each of the injections. For each of the office visits, you are only being charged a copayment of $20.85 because the allowed amount for each visit is less than your specialist copayment obligation. On the three dates when you received injections, the Plan appropriately also assessed 20% coinsurance for the drugs you received. That is why you had two separate cost sharing amounts. 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 the oncology visits you had from January 27, 2021, through April 28, 2021 and the Retacrit injections you received on January 27, 2021, February 24, 2021, and March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any skilled nursing needs and you do not require daily skilled therapy services at an inpatient level in a SNF. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the retainer crowns (D6750 x 2) and the pontic (D6240) provided on February 10, 2021.
You asked the Plan to pay for the fixed bridge. You say that you needed a new bridge due to sensitivity to cold. You also say that you thought your insurance would pay for a new bridge. The Plan denied your request. The Plan says that there is no specific physical or psychological condition(s) that preclude the use of a removable prosthesis.
The rules say a plan must disclose to its enrollees in clear, accurate terms under which dental services are covered. Your contract with the Plan does not say in clear and accurate terms that there are conditions to coverage of dental services. The rules also say that services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. We looked at your contract with the Plan. We did not see where the contract indicates there may be conditions to coverage for dental services, or specifically, the fixed prostheses. The Plan contract does not clearly state where to find the conditions for coverage of the fixed prosthesis. This means that the Plan did not follow Medicare rules. Additionally, the record shows that your existing prosthesis was 15 years old. Therefore, we decided that the Plan has to pay for the retainer crowns (D6750 x 2) and the pontic (D6240) provided on February 10, 2021.
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.