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

We decided that the Plan does not have to pay for the laboratory services and the hospital outpatient clinic visit rendered by the out-of-network (OON) provider on September 14, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services and the hospital outpatient clinic visit rendered by the out-of-network (OON) provider on September 14, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is felt that IRF care would be best for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 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 in the Medicare rules section.
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 enrollee is a female who was admitted to the hospital after a fall resulting in a right humerus fracture, which was treated with a sling. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on August 14, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the hospital ordered this transport, not you. You stated that you had family available who could have transported you. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on August 14, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from March 17, 2021, to May 20, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were not told that changing chemotherapy would make your cost so high. You said that you would have turned down these chemotherapy drugs if you had known the cost would be so high. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from March 17, 2021, to May 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care provided on June 20, 2021, and June 25, 2021.
You asked the Plan to waive the copayments for emergency care. You say that the emergency room did little to treat your condition and 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 $90 copayment for emergency care. You received emergency care on June 20, 2021, and June 25, 2021. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount you owe is: $180. You have been asked to pay the total copayment amount of $180 for emergency care. Emergency care 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 copayments for emergency care provided on June 20, 2021, and June 25, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a panoramic
radiographic imaging (D0330) provided by a participating provider on June 15, 2021.
You asked the Plan to pay for a limited oral evaluation, and a panoramic radiographic imaging. You say that
you would like the Plan to reprocess and pay this claim. The Plan denied your request. The Plan says this
appeal was processed correctly.
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. The total amount you are being asked to pay is $190.50. Therefore, we
decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a panoramic radiographic
imaging (D0330) provided by a participating provider on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for low osmolar contrast material provided on July 16, 2021.
You asked the Plan to waive the coinsurance for low osmolar contrast material. You say that you disagree with the denied 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 medical supplies. You received low osmolar contrast material on July 16, 2021. This is considered medical supplies. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $105.14 and
20% of that is $21.03. You have been asked to pay the total coinsurance amount of $21.03 for low osmolar contrast material. Low osmolar contrast material 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 low osmolar contrast material provided on July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on January 21, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate code for the services billed.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Specifically, the claim was billed by a physician who did not render the service. There is no evidence that the physician provided direct supervision. Incident-to criteria have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on January 21, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on February 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on February 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 27, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you did not receive the right test and disagree with 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 $10 copayment for laboratory services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 laboratory services provided on August 27, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7140 and D7210) and maxillary tissue conditioning (D5850) provided by an out-of-network provider on May 6, 2021.
You asked the Plan to pay for a tooth extraction (D7140 and D7210) and maxillary tissue conditioning (D5850). You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says this claim has been processed correctly.
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 a tooth extraction (D7140 and D7210) and maxillary tissue conditioning (D5850) provided by an out-of-network provider on May 6, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), pontics (D6245 x 2), and
prefabricated post and core in addition to a crown (D2954) provided on August 11, 2021.
You asked the Plan to pay for the dental services. You say that this decision is a mistake. You say that you
were told your plan pays 25% for crowns. You also say that 25% should be paid for the crowns. The Plan
denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics
are not listed as covered services. The Plan says that prefabricated post and core in addition to a crown is not
listed as a covered service either. The Plan also says that you were advised that coverage for dental services is
code specific.
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 retainer crowns, pontics, and
prefabricated post and core in addition to a crown are not among those covered under this benefit. Therefore,
we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), pontics (D6245 x 2), and
prefabricated post and core in addition to a crown (D2954) provided on August 11, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trintellix.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is not part of the health plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for open treatment of a broken ankle with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria has not been met for an out-of-network exception.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for open treatment of a broken ankle with an out-of-network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Certolizumab Pegol.
You asked the Plan to pre-approve Certolizumab Pegol. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Certolizumab Pegol. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has joint pain related to psoriatic arthritis. The documentation does not support that the enrollee has had a trial of Remicade (or Renflexis). The documentation does not support an indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Certolizumab Pegol have not been met. Therefore, we decided that the Plan does not have to pre-approve Certolizumab Pegol.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ezetimibe.
You asked the Plan to pre-approve Ezetimibe. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ezetimibe.
Benefits for Ezetimibe may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation and office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office consultation and office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office consultation and office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210) and limited oral exam (D0140) provided on July 8, 2021.
You asked the Plan to pay for the extractions and limited oral exam. You say that you would like reconsideration because you were told that the Plan would pay for a portion of this service. The Plan denied your request. The Plan says this claim has been processed correctly.
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 limited oral exam is not among those covered under this benefit. Additionally, you have been asked to pay a 50% coinsurance for the
extractions. This is the correct coinsurance per your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the extractions (D7210) and limited oral exam (D0140) provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 13, 2021, to July 30, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not understand why you are being charged a copayment when you do not owe a copayment for other services. 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 per admission for inpatient hospital care. You have been asked to pay a $300 copayment per admission for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from July 13, 2021, to July 30, 2021.