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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 27,
2020.
You asked the Plan to waive the copayment for the laboratory tests. You say that everything was done at the
doctor's office. You say that you thought you weren't supposed to be charged since the visit was a yearly
physical. The Plan denied your request. The Plan says the copayment 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 $50
copayment for lab services at an in-network outpatient hospital.
You have been asked to pay a $50 copayment for the laboratory tests. The laboratory tests fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the
laboratory tests were 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 laboratory
tests provided on January 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 24, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were informed you couldn't drive to the hospital. You say that the copayment should be paid by the office. The Plan denied your request. The Plan says the copayment 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 $150 copayment per trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 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 December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the eyewear provided on October 22, 2019.You asked the Plan to provide additional reimbursement for the eyewear. You say that this should be covered at 100%.The Plan denied your request. The Plan says that the claim processed correctly.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 apply in this case. The Plan covers up to a $100 for eyeglasses or contact lenses every year.We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly benefit of $100 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount.Therefore, we decided that the Plan does not have to provide additional reimbursement for the eyewear provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like reconsideration because the IRF admission is medically necessary.The Plan denied your request. The Plan says the records do not show that the member has a need for intensive rehabilitation, complex medical conditions which require physician supervision and a multidisciplinary team for their care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the member was medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation physician or need for acute rehab nursing care. There is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 14, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 a domiciliary, rest home visit provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide cover age for an additional 20 routine transportation trips.You asked the Plan to provide coverage for the additional 20 routine transportation trips. You say that you cannot drive and you have no other means for transportation to doctor's visits. The Plan denied your request. The Plan says your benefit only allows for 24 one-way trips for the plan year and any additional trips are not covered by the health plan.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 for up to 24 one-way transportation trips per calendar year.We looked at your request, the records in the case file, and the rules.The file shows that the Plan covers up to 24 one-way transportation trips per calendar year.Therefore, we decided that the Plan does not have to provide coverage for an additional 20 routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 3, 2020 to January 30, 2020.
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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x type of bill. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from January 3, 2020 to January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a power wheelchair power seat elevation feature.You asked the Plan to provide a power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair, accessories and a power seat elevation feature.The Plan denied your request. The Plan says a power seat elevation feature does not serve a medical purpose.The Plan follows Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.A power seat elevation feature does not serve a purpose that is primarily medical in nature and is not covered by Medicare.Therefore, we decided that the Plan does not have to provide a power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venous device irrigation provided on February 7, 2020.
You asked the Plan to waive the copayment for the venous device irrigation. You say that you were told you need this every month. You say that you shouldn't have to pay the copayment. The Plan denied your request. The Plan says the copayment 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 $375 copayment for outpatient hospital services. You have been asked to pay $63.26, which is less than the standard $375 copayment for the venous device irrigation. The venous device irrigation falls within the "Outpatient hospital 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 venous device irrigation provided on February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram and the ultrasound provided on February 20, 2020.
You asked the Plan to waive the deductible for the mammogram and the ultrasound. You say that this was a routine screening to check a previous area of tenderness as noted on last year's exam. 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. Your contract with the Plan says that there is a $250 deductible that applies towards diagnostic mammograms and ultrasounds. The mammogram and the ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards diagnostic mammograms and ultrasounds. The record shows a diagnosis code for 'other disorders of the breast' which makes the mammogram and ultrasound diagnostic in nature.
This cost sharing is a contractual obligation that had not been met at the time the mammogram and the ultrasound were received on February 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the mammogram and the ultrasound provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered by an out-of-network provider on December 18, 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 the services were rendered by an out-of-network provider without prior authorization.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services rendered by an out-of-network provider on December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 22, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not request an ambulance. You say that you do not agree with the copayment. The Plan denied your request. The Plan says the copayment 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 Medicare-covered ambulance services. You pay this amount for each one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance 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 ambulance transport provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fittings for foot orthotics and braces.
You asked the Plan to pre-approve fittings for foot orthotics. You say that you have foot pain and need shoe inserts. 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. The inserts are not part of a leg brace. The records do not show how a leg brace will be used to improve function. 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 pre-approve fittings for foot orthotics or ankle braces.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foreye surgery (66984) provided on November 29, 2018.You asked the Plan to pay foreye surgery. You say that this was filed timely.The Plan denied your request. The Plan says this was filed more than a year after the date of service.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 eye surgery was not filed until January 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decidedthat the Plan does not have to pay foreye surgery (66984) provided on November 29, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on February 27, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges due to an incident caused by an employee at a rehab facility. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on February 27, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit option, plastic coated hand rims and removable sideguards. You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that a non-medical feature that is intended for use outside the home is not considered DME and is statutorily 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a transit option, plastic coated hand rims and removable sideguards.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan doesnot have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection and its administration provided on December 17, 2019.
You asked the Plan to waive the cost share for the injection and its administration. You say that you believe you are being overcharged for the injection. You say you are asking for the charges to be lowered. 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 20% coinsurance for each Medicare-covered Part B drug and a $345 copayment for the administration of the injection. You have been asked to pay $231.31 which is 20% of the allowed amount for the injection. The allowed amount is $1,217.05. ($1,217.05 x 20% = $231.31). You have also been asked to pay $12.10 for the administration of the injection which is less than the standard copayment amount. ($231.31 + $12.10 = $243.41).
The injection falls within the "Medicare Part B Prescription Drugs" benefit category. The administration of the injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the injection and its administration provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on November 4, 2019 by an
OON provider.
You asked the Plan to pay for the occlusal guard. You say that you contacted the Plan and were given
permission to see this provider. The Plan denied your request. The Plan says this service was rendered by an
OON provider. The Plan also says that occlusal guard is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
occlusal guard provided on November 4, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.You asked the Plan to pre-approve the bed. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound and x-ray services provided on February 10,
2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an OON 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 ultrasound and x-ray services provided on
February 10, 2020 by an out of network (OON) provider.