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

We decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you were tricked into believing this policy was as good as your previous policy and cannot afford this charge.The Plan denied your request. The Plan says the denial of payment forthis service is correct, because this provider is out-of-network with the Plan and prior authorization 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 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 medical services provided on January 10, 2020 by an out of network (OON) provider.Your complaint regarding receiving inaccurate information about the benefits of this Plan contract is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bilateral breast tomosynthesis rendered on August 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 77063 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 77063 is screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).We find that CPT code 77063 is not supported in the medical record. Specifically, this code is an add-on code that was not billed with a required primary procedure code. 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 forthe bilateral breast tomosynthesis rendered on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visits provided on December 31, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that the nurse practitioner works for your primary care physician and you should not be charged a copayment. 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 $25 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed by a cardiologist office, which is considered a specialist office.
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 specialist office visits provided on December 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on November 5, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were related to an automobile accident. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the automobile insurance as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services you received on November 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 2, 2019 to December31, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says home health claims are required to have the appropriate treatment authorization code and q code. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted does not include the required treatment authorization or q codes.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 2, 2019 to December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on December 27, 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 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) audio logic function tests (92557) canalith repositioning procedure (95992) provided January 14, 2020.You asked the Plan to waive the copayment for the diagnostic outpatient office visit. You say that you benefits show that a hearing test is covered at no cost each year. You are being billed $10 for what you believed to be a standard hearing test.The Plan denied your request. The Plan says this claim processed correctly per the EOC.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment for diagnostic lab services and diagnostic procedures and tests. You have been asked to pay $10. The diagnostic outpatient office visit falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to paythe 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 outpatient office visit (99214) audiologic function tests (92557) canalith repositioning procedure (95992) provided January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on January 29, 2020.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you were told that there was no charge and that you were fully covered for the procedure. 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 $200 copayment per date of service at an ambulatory surgical center. You have been asked to pay a $200 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including 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 copayment for the upper GI endoscopy provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services provided on December 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 outpatient surgery services provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on September
11, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that due to your condition your
daughter was not allowed to drive you to the hospital. 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip 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 an ambulance trip
provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the stress test and the PET scan provided on August 26, 2019.
You asked the Plan to waive the cost share for the stress test and the PET scan. You say that you were charged separately for other tests when you were only supposed to pay $200 for the PET scan. The Plan denied your request. The Plan says your claim was reprocessed and 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 15% of the cost for Medicare-covered diagnostic procedures and tests and a $200 copayment each Medicare-covered diagnostic radiology and complex imaging service. You have been asked to pay $10.64 which is 15% of the allowed amount for the stress test. The allowed amount is $70.92. ($70.92 x 15% = $10.64). You have also been asked to pay a $200 copayment for the PET scan. The stress test and the PET scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the stress test and the PET scan are considered separate 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 cost share for a stress test and the PET scan provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses (L1832, L1652) provided to the enrollee on November 2, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the orthoses (L1832, L1652) provided to the enrollee on November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 7, 2020 and February 4, 2020.You asked the Plan to waive the copayment for the office visits. You say that you are on a fixed income. You say that you cannot afford to pay $50 a month.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 $25 copayment for each out-of-network individual/group Medicare-covered therapy visit.You have been asked to pay a $25 copayment for each office visit. The total amount you owe is $50 ($25/visit x 2 visits = $50). The office visits fall within the "Outpatient mental health 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 the office visit provided on January 7, 2020 and February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on December 11, 2019.
You asked the Plan to pay for the hearing aids. You say that you went to this provider because they were
advertised and they told you that you would be covered for $1000 every 3 years. You feel that this should be
covered and you want your reimbursement. The Plan denied your request. The Plan says enrollee's must
receive their hearing services from an in-network provider. Non-emergent services with non-contracted
providers require prior-authorization prior to services being rendered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when the services are provided by a network provider per page 51 of the plan's 2019
Evidence of Coverage.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you live alone and on a limited income. You say that you need the requested stair lift because you get dizzy going up and down the stairs. You stated that you have had near misses from falling down the stairs several times and you have problems with your feet and knees. You say that you lose your balance when you are going up the stairs and when you have to carry things up them it is even worse. You stated that the requested stair lift would help you and you requested that the Plan approve it because of your medical conditions. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray (73564) provided January 9, 2020.You asked the Plan to waive the copayment for the X-ray. You say that the copayment for the x-ray should be included in the office visit copayment.The Plan denied your request. The Plan says a separate copayment is charged for each service in the outpatient setting.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 X-ray and Ultrasounds. You have been asked to pay a $40 copayment for the X-ray. The X-ray falls within the X-ray and Ultrasounds 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 X-ray (73564) provided January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 1, 2019.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 payment for this ambulance transport is included in the SNF Part A stay as per Medicare guidelines.The Plan must follow Medicare rules. The rules say that when Medicare pays for Part A SNF services patient transportation to a physician office falls under consolidated billing for the SNF. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office while the enrollee was under inpatient status with a SNF.Therefore, we decided that the Plan does not have to pay for the transport to a physician's office provided on October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 12,
2019 and the PET scan provided on December 16, 2019.
You asked the Plan to waive the copayment for the CT scan and PET scan. You say that you were informed
you shouldn't be charged. You say that you shouldn't have out-of-pocket charges. 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 advanced imaging or nuclear medicine services in a physician office or outpatient facility
setting, in addition to any applicable office visit or facility copayment.
You have been asked to pay $361.15 for the CT scan and PET scan.
Date of Service Service Allowed Amount Standard Copayment Member Liability
November 12, 2019 CT Scan $61.15 $300 $61.15
December 16, 2019 PET Scan $1,350.20 $300 $300
TOTAL: $361.15 The CT scan and PET scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies"
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 CT scan provided on
November 12, 2019 and the PET scan provided on December 16, 2019.