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

We decided that the Plan does not have to waive the coinsurance for the Gel-One injections provided on August 12, 2020.
You asked the Plan to waive the coinsurance for the Gel-One injections. You say that the Plan approved the injections but you were never instructed that you would have to pay any kind of charge. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Gel-One injections. The Gel-One injections fall within the 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 Gel-One injections provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on August 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON radiology services. You say that you were under the impression you were in-network. You say that you received a letter in January of 2020 that stated you were receiving the guide because you were identified as a provider in a long-term care facility in which the Plan had members enrolled. The Plan denied your request. The Plan says there was no authorization for the services provided OON.
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 had 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. The letter you reference having received only states that you were identified as a provider who works in a facility in which Plan members were enrolled. It does not say that you are contracted with the Plan, are considered in-network, or that prior authorization is not required. 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 radiology services provided on August 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the chiropractic services provided from July 22, 2020, to August 12, 2020 by an out of network provider.
You asked the Plan to reimburse you for the chiropractic services. You say that The Plan should reimburse you for the services. The Plan denied your request. The Plan says these codes are not payable by Medicare.
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 reimburse you 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. This provider has opted out of Medicare. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. CPT codes 97114 and S8990 are not valid codes for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for the chiropractic services provided from July 22, 2020, to August 12, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 10, 2020 by an out of network provider.
You asked the Plan to pay for the physician services. You say that your doctor should not be penalized for the staff's failure in obtaining authorization. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided 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 the physician services provided on July 10, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the chiropractic and imaging services provided on November 18, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that you feel you should get reimbursed. The Plan denied your request. The Plan says the claim processed 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).
The file shows that you received an x-ray of the spine. You have been asked to pay $36.70 for the x-ray. The service falls within the outpatient diagnostic test benefit category. At the time of service, you had not met your $750 deductible amount. This means that you have been asked to pay the correct amount based on your contract with the Plan. You have been asked to pay an $18 copay for the chiropractic services. The services fall within the chiropractic services 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 cost shares for the chiropractic and imaging services provided on November 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport (A0429) and mileage (A0425) provided on September 9, 2020.
You asked the Plan to waive the copayment for ambulance transport and mileage. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance transport and mileage. These services fall within the ambulance services 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 ambulance transport (A0429) and mileage (A0425) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to obtain the proper authorization. The Plan denied your request. The Plan says authorization for out-of-network services 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport (A0428) and mileage (A0425) to a physician's office provided on October 7, 2020.
You asked the Plan to pay for non-emergent ambulance transport and mileage. You say that the service should be covered. The Plan denied your request. The Plan says a physician's office/clinic/outpatient center is not a covered destination; transport could have been made by a van or other vehicle.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when covered services do not include transportation by ambulance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the transportation was routine and could have been made by a van or other vehicle. Transportation by ambulance to a physician's office is not a covered service. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport (A0428) and mileage (A0425) to a physician's office provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that no authorization was obtained. The Plan denied your request. The Plan says the enrollee's plan requires the utilization of in-network providers.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve 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 medical services provided on July 24, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided from October 1, 2020, to October 2, 2020.
You asked the Plan to waive the copay for the services provided. You say that you were admitted to the hospital. The Plan denied your request. The Plan says no inpatient admission occurred.
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 $90 copay for each Medicare covered emergency room visit. You have been asked to pay a $90 copay for the services provided. The services fall within the emergency care benefit category. There is no documentation to show that you were admitted to the hospital for inpatient services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the emergency room services provided from October 1, 2020, to October 2, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the dialysis services provided from January 2, 2020 to January 4, 2020.
You asked the Plan to pay for the dialysis services. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says that the services were provided by an out of network dialysis facility without prior authorization. There are in-network providers able to furnish this care.
The Plan must follow Medicare rules. Medicare rules say that health plans must covered all medically necessary dialysis services provided to an enrollee who is temporarily out of the service area without any requirement for prior authorization or notification. These dialysis services were provided while the enrollee was a resident which is outside of the plan's service area. As these services were provided out of area, denial based on lack of authorization is not appropriate. There was no argument made that these services were not medically necessary or that there was a coding issue. As such, the rules for coverage of this dialysis care have been met. Therefore, we decided that the Plan has to pay for the dialysis services provided from January 2, 2020 to January 4, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on November 5, 2019 and billed under code 73630.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus has issued an overturn decision stating that must pay for code 73630 provided on November 5, 2019. It has been determined that this claim was denied because the provider did not bill with the appropriate modifier to show what side of the body the service was performed on. According to our review, the anatomic-specificmodifiers LT(Left  side),RT(Right  side),and 50 (Bilateral  procedure) designate the area or part of the body on which the procedure is performed. The case file includes the claim image that shows these modifiers were not billed by the provider, but we found they are required whenever they are appropriate.The Medicare Claims Processing Manual Chapter 4 Section 20.6.3 explains that Modifiers -LT or -RT applyto codes which identify procedures which can be performed on parts of the body. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to identify which of the paired organs was operated upon. These modifiers are required whenever they are appropriateand were not reported on this claim. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes and when necessary the modifiers associated with the service provided. In this case, this claim cannot be paid as billed due to the omission of the required modifiers. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on November 5, 2019 and billed under code 73630.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for surgical lesion destruction services you received at an outpatient hospital facility.
You asked the Plan to reduce the copayment for the surgical lesion destruction services. You say that you had these same services done in Florida and only had to pay an office visit copayment. The Plan denied your request. The Plan says the facility where you had these services participates in hospital-based billing, so you were charged this cost sharing 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 $200 copayment for surgical services in an outpatient hospital facility. You have been asked to pay a $200 copayment for the surgical lesion destruction services. The facility where you had these services bills as an outpatient hospital facility. 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 reduce the copayment for surgical lesion destruction services you received at an outpatient hospital facility.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services received on July 22, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this provider is not Medicare-certified.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program 

The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services received on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine eyewear purchased on August 29, 2020.You asked the Plan to pay forthese services. You say that you were told that you could submit a receipt and would be reimbursed.The Plan denied your request. The Plan says services from a non-participating provider are not covered.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 applyin this case. The Plan covers these services when they are performed by a participating provider.We looked at the file and the Plan's rules. The file shows that you received services from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe routine eyewear purchased on August 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost stabilization services provided from June 21, 2020, to June 22, 2020.You asked the Plan to pay forthe post stabilization services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the enrollee was stable for transfer on June 21, 2020.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for post stabilization services. Our reviewer says that the enrollee was stable for transfer. Our physician reviewer found there is documentation of the patient being stable for transfer and was not notified in a timely fashion. Denial upheldWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post stabilization services have not been met.Therefore, we decided that the Plan does not have to pay forpost stabilization services provided from June 21, 2020, to June 22, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for preventive procedure (D1999), periodontal maintenance (D4910), oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), periodontal procedure (D4999) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381) provided on August 14, 2020.

You asked the Plan to pay for preventive procedure, periodontal maintenance, oral hygiene instructions, topical application of fluoride varnish, periodontal procedure and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered under your benefit plan.

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. Specifically, the services are not listed in the Plan's supplemental dental benefit chart. This means the services are not covered under your benefit plan. Therefore, we decided that the Plan does not have to pay for preventive procedure (D1999), periodontal maintenance (D4910), oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), periodontal procedure (D4999) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381) provided on August 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization care provided from June 14, 2020, to
June 15, 2020.
You asked the Plan to pay for the post stabilization care. You say that the Plan was notified but did not
promptly transfer the enrollee. The Plan denied your request. The Plan says the enrollee's emergency medical
condition stabilized and you failed to request authorization for post stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the post stabilization care. Our reviewer says
that the enrollee should have been transferred. Our physician reviewer agrees with the determination that the
patient was stable for transportation to a facility, and that the notification was not timely enough, and
agrees with the denial of post-stabilization 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 the post stabilization care have not been met. Therefore, we decided that the
Plan does not have to pay for the post stabilization care provided from June 14, 2020, to June 15, 2020.