Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided from August 6, 2019 to September 16, 2019 by out of network provider.
You asked the Plan to pay for the oxygen services. You say that you did not think your doctor would have authorized the oxygen because you hadn't seen her in a year. The Plan denied your request. The Plan says the provider was denied approval on March 16, 2018 and told to transition you to an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the oxygen services provided from August 6, 2019 to September 16, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 24, 2019 to August 12, 2019.You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancetdevice provided from May 24, 2019 to August 12, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe probing of nasal-tear duct provided on July 12, 2019.You asked the Plan to waive the copayment forthe probing of nasal-tear duct. You say that you did not receive a surgical procedure and disagree withthe 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 (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery services provided in an outpatient hospital facility.The medical records show that you received the probing of nasal-tear duct provided on July 12, 2019.The probing of a nasal-tear duct is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a$150 copayment for the probing of nasal-tear duct. The probing of nasal-tear duct falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you havebeen 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 forthe probing of nasal-tear duct provided on July 12, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not submitted progress notes that are needed to determine the clinical utility of the testing.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on June 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care services provided from December 27,
2018 to January 10, 2019 by the Provider.
You asked the Plan to pay for the post-stabilization care services. You say that the services were medically
necessary. The Plan denied your request. The Plan says prior authorization was not requested or received for
the services, therefore coverage criteria has not been met.
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 services. Our reviewer says that the services were not medically necessary. Our physician reviewer found in this case, the enrollee was stabilized in the emergency department and should have been considered for transfer to an approved facility. Alternatively, approval could have been sought to admit the enrollee to the same hospital. A request for pre-approval was not initiated as required by the plan. Without the request or granted pre-approval, post stabilization care (care delivered after emergency department stabilization) cannot be approved. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care services provided from December 27, 2018 to January 10, 2019 by the Provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on July 8, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be charged for a full office visit because the provider did not do anything. 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 $45 copayment if office visit services are provided by a specialist. You have been asked to pay a $45 copayment for the specialist office visit. the specialist office visit falls within the if office visit services are provided by a specialist benefit category. The medical record shows you were seen for a follow-up evaluation.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 forthe specialist office visit provided by "the provider" on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the difference in upgrade to progressive lenses provided on May 9, 2018.You asked the Plan to reimburse you for the upgrade to progressive lenses. The Plan denied your request. The Plan says the benefit limit has been reached.Medicare generally does not cover routineeyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules apply in this case. The Plan covers theseservices every year.We looked at the file and the Plan's rules. The file shows that you received the routine eyewear benefit on May 9,2018, which the Plan paid the benefit limit.Upgrade benefits do not count towards the $150 per-year limit on eyewear. Therefore, we decided that the Plan does not have to reimburse you for the difference in upgrade to progressive lenses providedon May 9, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on July 15, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you had to leave the emergency room to get your medication. 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 $90 copayment for emergency services at an in or-out-of-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within "Emergency care" benefit category. The record shows you received laboratory services during your emergency room visit.
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 visit provided by the Medical Center on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided by the Provider on August 26, 2019.
You asked the Plan to pay for the chemotherapy services. You say that you disagree with the amount reimbursed. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 for Medicare Part B drugs. The Plan says you must pay 35% coinsurance for the chemotherapy services. Review of the file plan contract shows that nowhere does it state that you are to pay 35% coinsurance for these chemotherapy services. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the chemotherapy services. Therefore, we decided that the Plan does not have to pay for the chemotherapy services provided by the Provider on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided.
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says records supporting medical necessity were requested but not received.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urgent care services rendered to you on August 8, 2019 and August 13, 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 procedure code S9088 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider submitted a claim for procedure code S9088 (services provided in an urgent care center). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay for the urgent care services rendered to on August 8, 2019 and August 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided by the Provider on February 13, 2018.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until May 13, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for services provided by the Provider on February 13, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the psychotherapy visits provided from January 3, 2019 to May 30, 2019.
You asked the Plan to reduce the coinsurance for the psychotherapy visits. You say that you were told you would have a $30 copayment for your out-of-network visits. 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 50% of the cost for out-of-network individual/ group psychiatric services. You have been asked to pay $1,731.38 for the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health care" benefit category. See chart below.
Dates of Service
Service
Allowed Amount per Visit
Coinsurance
Member Liability per Visit
Number of Visits
Member Liability x Number of Visits
January 3, 2019 to April 29, 2019
Psychotherapy
$138.51
50%
$51.94
24
$1,246.56
May 6, 2019 to May 30, 2019
Psychotherapy
$103.88
50%
$69.26
7
$484.82
Total
$1,731.38
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 coinsurance for the psychotherapy visits provided from January 3, 2019 to May 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 2, 2018 and June 22, 2019.
You asked the Plan to waive the copayment for the ambulance transports. You say that this is a lot of money that you don't have. You say that this is why you have insurance. 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 $300 for Medicare-covered ambulance services per day. You have been asked to pay a $300 copayment for the ambulance transport on November 2, 2018 and a $225 copayment for the ambulance transport on June 22, 2019. The total amount you owe is $525 ($300 + $225 = $525). The ambulance transports 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 the ambulance transport provided on November 2, 2018 and June 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for foot orthotics purchased on July 2, 2019.
You asked the Plan to reimburse you for foot orthotics. You say that you need the orthotics for your back, hip, knee and ankle pain and you were told the orthotics were covered. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to reimburse you for foot orthotics purchased on July 2, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the eye injections and Part B drugs provided on November 30, 2018. We decided that the Plan does not have to waive the cost share for the eye injections and Part B drugs provided from January 11, 2019 through September 10, 2019.. You asked the Plan to waive the cost share for the eye injections and Part B drugs. You say that the only equipment used was a syringe and needle. You say that none of the charges are valid.The Plan says that the cost share applied correctly.
We decided that the Plan has to waive the cost share for the eye injections and Part B drugs provided on November 30, 2018. 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 2018 Evidence of Coverage was not submitted to verify that the correct cost share was applied. Therefore, we decided that the Plan has to waive the cost share for the eye injections and Part B drugs provided on November 30, 2018.We also decided that the Plan does not have to waive the cost share for the eye injections and Part B drugs provided from January 11, 2019 through September 10, 2019..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 $250 copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center and 20% coinsurance for each Medicare-covered Part B drug.Therefore, we decided that the Plan does not have to waive the cost share forthe eye injections and Part B drugs provided from January 11, 2019 through September 10, 2019..If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe visiting nurse services provided to the enrollee on April 23, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization to receive care from an out of network provider.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 visiting nurse services provided to the enrollee on April 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on June 20, 2018 by the out of network provider.You asked the Plan to pay forthe physician services. You say that authorization is not needed for services provided by an urgent care facility. You also say the enrollee felt it was an urgent matter and needed to be seen right away.The Plandenied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee self-directed for the services. The Plan also says the service provided was not urgent or emergent.Medicarerules 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 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 office visit provided on June 20, 2018 by the out of network provider.