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

We decided that the Plan does not have to pay for therapeutic services provided on March 12, 2020, March 14,
2020 and
March 17, 2020.
You asked the Plan to pay for the therapeutic services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 therapeutic services provided on March 12, 2020, March 14,
2020 and March 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services provided on December 17, 2019You asked the Plan to pay forthe psychotherapy services. You say that the enrollee's hospice stay had ended on December 13, 2019. You also say that the enrollee wasseen by your facility after leaving hospice.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules saythat Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 13, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe psychotherapy services provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveepidural steroid injections.You asked the Plan to pre-approvethe epidural steroid injections. You say that you would like reconsideration because the member has experienced adequate pain relief from these injections in the past.The Plan denied your request. The Plan says the record does not show that the member has experienced adequate pain relief from prior injections.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 epidural steroid injections. Our reviewer says thatthe requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the member has had a prior injection on April 7, 2020 to this area with reported 65% relief one week later. There is no documentation of at least 50% relief that lasted for at least 3 months.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 epidural steroid injections have not been met.Therefore, we decided that the Plan does not have to pre-approveepidural steroid injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 9, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial imaging provided on January 21, 2020.
You asked the Plan to waive the copayment for myocardial imaging. You say that you were told that if the test was diagnostic then you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for advanced imaging and nuclear medicine. You have been asked to pay a $300 copayment for myocardial imaging. Myocardial imaging falls 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 myocardial imaging provided on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on January 8, 2020 to January 14, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee should not be responsible for the 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for each day for days 1 to 3 for Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. The enrollee has been asked to pay a $325 copayment for each day, for days 1 to 3 of the inpatient hospital stay. ($325 x 3 = $975). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by on January 8, 2020 to January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 23, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all white glass crown.
You asked the Plan to pre-approve an all white glass crown. You say that you need this for your health. The
Plan denied your request. The Plan says that this 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 pre-approve an
all white glass crown.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 13,
2020 through March 14, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you thought this was
observation and you would have to pay for the emergency room. 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 $295
copayment per admission.
You have been asked to pay a $295 copayment for the inpatient stay. The inpatient stay falls within the
"Inpatient hospital care" benefit category. The records show that you were admitted as an inpatient. 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 inpatient stay provided from March 13, 2020 through March 14,
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided
from March 17, 2018 to July 10, 2018.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you developed
PTSD from the mental health care you received and feel that you should not be responsible for the 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for outpatient mental health care.
You received outpatient mental health care from March 17, 2018 to July 10, 2018 for a total of 7 visits.
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 7 (outpatient mental health care) = $280.
You have been asked to pay the total copayment amount of $280 for outpatient mental health care. Outpatient
mental health care falls 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 copayments for outpatient mental health care provided from March 17, 2018 to July 10, 2018.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment forthe arthrocentesis provided on February 21, 2020.You asked the Plan to waive the copayment forthe arthrocentesis. You say that you were previously charged less for the same service. You say that the cost increased and you want to know why.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 per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $200 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure that was provided 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 forthe arthrocentesis provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair. Medicare does not cover the upholstered portion of a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that you need a seat lift chair. The Plan denied your request. The Plan says there is no documentation supporting medical necessity.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked the file and Medicare rules. The supplier was unsuccessful in obtaining documentation, from your physician, supporting the medical necessity criteria for a seat lift chair. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair. Medicare does not cover the upholstered portion of a seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) (K0554).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs to monitor her blood sugar. The Plan denied your request. The Plan says the enrollee does not use insulin.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered only if the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. We looked at the file and Medicare rules. The record does not show that the enrollee is insulin-treated as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extraction of tooth #4 (D7210) and therapeutic parenteral drugs (D9612) and general anesthesia, first 15 minute (D9222) general anesthesia, each 15 minute increment (D9223). You asked the Plan to pre-approvethe dental services. You say that you need this authorization approved because you are in extreme amount of pain and cannot eat. You cannot afford the out of pocket cost of $780.The Plan denied your request. The Plan says these services are not covered under the plan benefits.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 dentalbenefit 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 pre-approvesurgical extraction of tooth #4 (D7210) and therapeutic parenteraldrugs (D9612) and general anesthesia, first 15 minute (D9222) general anesthesia, each 15 minute increment (D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have plantar fasciitis pain in both feet.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 pre-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies
provided on February 13, 2020.
You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that the
prosthetic did not fit right and you disagree with the high 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for prosthetic devices and related supplies.
You received prosthetic devices and related supplies on February 13, 2020. The total allowed amount is
$8,005.90 and 20% of that is $1,601.18.
You have been asked to pay the total coinsurance amount of $1,601.18 for prosthetic devices and related
supplies. Prosthetic devices and related supplies fall within the prosthetic devices and related 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 coinsurance for prosthetic devices and related supplies
provided on February 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had just returned from a nine hour stay in the emergency room and you were extremely fatigued by it. You say that the fatigue, dehydration, and the drop in your blood sugar levels is what cause the hypotensive episode. Your son called 911 for an ambulance and the responders offered to transport you to the emergency room or to treat and monitor you in your home. You stated that you decided to be treated with IV fluids in your home and after the treatment you began to feel better. You say that the hypotension was completely resolved and the ambulance responders agreed that you were stable. You declined transportation to the hospital and you say that if you had gone, it would have cost the Plan far more money. You asked the Plan to reconsider their denial of the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 7, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on February 17, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you were told you were covered by insurance at the hospital. 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 $95 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $95 copayment for the x-ray.

The x-ray falls 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 x-ray provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy (97012), electrical stimulation (G0283), and the chiropractic manipulativetreatment, extra-spinal, one or more regions(98943)provided on February 26, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services provided do not meet Medicare criteria for coverage of chiropractic services.Therefore, we decided that the Plan does not have to pay forthe mechanical traction therapy (97012), electrical stimulation (G0283), and the chiropractic manipulativetreatment, extra-spinal, one or more regions (98943) provided on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the EKG provided on October 10, 2019.You asked the Plan to waive the coinsurance for the EKG. You say that you were not informed about the copayment for the procedure. You say that the EKG was not required.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for diagnostic tests and procedures. You have been asked to pay $3.98, which is 20% of the allowed amount for the EKG. The allowed amount is $19.90 (20% x $19.90 = $3.98). The EKG falls 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 coinsurance for the EKG provided on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 2, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on January 2, 2020.