Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided on December 9, 2019 and January 6, 2020.You asked the Plan to waive the copayment for occupational therapy. You say that the occupational therapy was not performed in an outpatient hospital. You say that the copayment should be $10 per visit.The Plan denied your request. The Plan says the copayments 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 $40 copayment for occupational therapy at an in-network outpatient hospital.You have been asked to pay a $40 copayment for each occupational therapy visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). Occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that the occupational therapy was billed by 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 occupational therapy provided on December 9, 2019 and January 6, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 the services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. She has not tried and failed the plan's required drug of zoledronic acid. The records do not support that the required drug would be less effective or contraindicated; therefore, Prolia is not reasonable or medically necessary at this time. 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 Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says the enrollee obtained a CT of the chest in early March of 2020. The Plan says that it is not medically necessary for the enrollee to have a repeat CT scan of the chest.
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 CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee had a CT of the chest in 2019. A follow-up was done in March of 2020 which showed a pulmonary nodule. Our physician reviewer says that they agree that a biopsy should be performed rather than a 3-month follow-up CT of the chest. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on November 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for the vision services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 vision services provided on November 29, 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 the complete series of intraoral x-rays (D0210) provided on November 18, 2019.You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like to know why this service is not covered.The Plan denied your request. The Plan says this treatment has a limit to how often it can be paid in three years. The Plan also says that the limit has already been reached.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, intraoral complete series are limited to once every 36 months. The record shows that you received a complete series of intraoral x-rays on May 3, 2018 and your intraoral complete series benefit has been exhausted.Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on November 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown, abutment supported porcelain/ceramic crown, and core buildup, including any pins when required provided by an OON dentist on December 16, 2019.
You asked the Plan to pay for the re-cement or re-bond of a crown, abutment supported porcelain/ceramic crown, and core buildup. You say that you spoke with a plan representative before receiving these services and were told that they would be covered. The Plan denied your request. The Plan says you self-referred to an out-of-network provider for dental services. The Plan also says that you called prior to receiving the services and were told that there were in network options available for the services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of a crown, abutment supported porcelain/ceramic crown, and core buildup, including any pins when required provided by an OON dentist on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on April 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for podiatry services. You say that the member told you that they had Medicare. You say that you are requesting the Plan remit payment due to the enrollee providing misleading information.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 podiatry services provided on April 18, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided from June 17, 2019 to
September 12, 2019.
You asked the Plan to pay for outpatient mental health care provided from June 17, 2019 to September 12, 2019. You say that this care was medically necessary. The Plan denied your request. The
Plan says this provider is not eligible to accept Medicare payment.
You provided additional information directly to our office regarding the necessity of this treatment. It should be
noted that in your information you state the dates in question are June 17, 2019 to December 12, 2019, instead
of September 12, 2019. MAXIMUS can only address the dates of service reviewed by the Plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for services rendered by physician or practitioner who is not a Medicare eligible provider. The question is not
whether the services were medically necessary, but that the services were provided by a practitioner who is not
considered by Medicare to be an eligible to provider. Therefore, we decided that the Plan does not have to pay
for outpatient mental health care provided by from June 17, 2019 to September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a transthoracic echocardiography (C8929) provided November 27, 2019.
You asked the Plan to waive the coinsurance for the transthoracic echocardiography. You say that you were told the copayment would only be $55. The Plan denied your request. The Plan says the correct cost share was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Outpatient Hospital Diagnostic Imaging. You have been asked to pay a 20% coinsurance for the transthoracic echocardiography. The transthoracic echocardiography falls within the Outpatient Hospital Diagnostic Imaging 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 a transthoracic echocardiography (C8929) provided November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the equine collagen primary wound dressings provided on October 4, 2019.
You asked the Plan to pay for the wound care supplies (A6021). You say that the supplies were medically necessary. The Plan denied your request. The Plan says the supplies are available in-network.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that the wound care supplies (A6021) was used in a SNF. Therefore, we decided that the Plan does not have to pay for the equine collagen primary wound dressings provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a specialist visit provided on November 12, 2019.
You asked the Plan to waive the deductible for a specialist visit. You say that there is no other provider within a reasonable distance and 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 physician/practitioner services, including doctor's office visits. You received a specialist visit on November 12, 2019 from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had only paid $326.93 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $111.76. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on November 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a specialist visit provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora TDAP vaccine (90715) provided on December 9, 2019.You asked the Plan to pay forthe TDAP vaccine. You say that you would like reconsideration because you were told you needed this vaccine beforevisiting your newborn grandchild.The Plan denied your request. The Plan says the services performed are not covered under regular Medicare Part B and therefore not covered by your Part B health care plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine.Therefore, we decided that the Plan does not have to pay fora TDAP vaccine (90715) provided on December 9, 2019.Benefits for the TDAP vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.Your complaint about receiving incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network on October 9, 2019.
You asked the Plan to pay for this service. You say that you believe the Plan should pay this bill. 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 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 service 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 physician services provided out of network on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network on December 19, 2019.You asked the Plan to pay for this service. You say that this service should be covered by the Plan.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 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 service 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 forphysician services provided out of network on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 6, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you were told that you would not owe a 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. You have been asked to pay a $35 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 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 visit provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physicians services provided on November 1, 2019 to November by an out of network (OON) provider.
You asked the Plan to pay for physicians services. You say that it is the facility's responsibility to obtained prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's stay has not been authorized by them.
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 physicians services provided on November 1, 2019 to November by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on February 28, 2019.
You asked the Plan to pay for outpatient services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network and the services were not urgent or emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 outpatient services. Our reviewer says that the services do not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could have foreseen requiring these services prior to leaving the Plan's service area. The records do not indicate that the care provided was medically necessary. Given that the visit was for a Medicare wellness visit, it would have been medically reasonable to delay the services until after February 28, 2019, when the enrollee disenrolled from the Plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services provided on February 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have the copayment for the inpatient hospital stay provided on November 30, 2019.
You asked the Plan the copayment for the inpatient stay. You say that you went to the emergency room and were not admitted to the hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day, for days 1-5, per admission. You have been asked to pay a $325 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The medical record shows you were admitted as an inpatient on November 30, 2019 and discharged on December 1, 2019.
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 the copayment for the inpatient hospital stay provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that the member is in a skilled nursing facility; therefore, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-network.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 forskilled nursing services provided on November 18, 2019 by an out of network (OON) provider.