Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation, bone replacement graft for ridge preservation, and autogenous connective tissue graft.
You asked the Plan to pre-approve the sedation, bone replacement graft for ridge preservation, and autogenous connective tissue graft. You say that you need this surgery for your future health. You also say that you deserve to have these medical procedures covered. The Plan denied your request. The Plan says the requested services are excluded from coverage by Medicare because they are non-covered dental services that are restorative in nature.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve sedation, bone replacement graft for ridge preservation, and autogenous connective tissue graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary interim complete denture (D5810).
You asked the Plan to pre-approve the maxillary interim complete denture. You say that your dentures broke, and you have had them for over 40 years due to gum disease. You also say that the broken denture is not affecting your bite and jaw, causing new problems and you cannot chew properly. The Plan denied your request. The Plan says dentures are not covered under your dental 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 a maxillary interim complete denture (D5810).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on June 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the claim was processed incorrectly. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87502, 87532,
87541, 87581, 87634, 87640, and 87798) provided on September 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate
place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS
31. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498,
87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 31, 2020, by
an OON provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered 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 had network providers
available who could have provided 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 laboratory services provided on December 31,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an overdenture (D5865), two surgical placements of implant bodies: endosteal implants (D6010 x2), and two custom fabricated abutments (D6057 x2).
You asked the Plan to pre-approve the overdenture, endosteal implants, and custom fabricated abutments. You say that implants are the only option for you to have teeth in your lower gums. You also say that you feel the implants are medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 overdenture (D5865), two surgical placements of implant bodies: endosteal implants (D6010 x2), and two custom fabricated abutments (D6057 x2).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy coded as S9502 provided from January 23, 2021, to January 26, 2021.
You asked the Plan to pay for the home infusion therapy. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this code is not eligible for payment under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code S9502 is not supported for payment in this case. Specifically, this code has a status indicator of "I" which indicates that no payment is made by Medicare for these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy coded as S9502 provided from January 23, 2021, to January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on March 29, 2021.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration because the service provided was contemporaneous and not a review of the radiologist's findings. The Plan denied your request. The Plan says it was unable to be determined how the member came to this provider.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Specifically, the record does not include sufficient information to determine if Medicare coverage criteria have been met. The documentation does not include any clinical information to determine how the member came to this provider, what services were rendered and if they were medically appropriate. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93010) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor excision services coded as 21930 provided on August 5, 2020.
You asked the Plan to pay for the tumor excision services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says an assistant at surgery is not payable for these services.
The Plan must follow Medicare rules. Medicare rules say that if the Medicare Fee Schedule Database contains an assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an assistant is not medically necessary.
We looked at the file and Medicare rules. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 21930. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based on this information, we decided that Medicare rules for coverage of the tumor excision services have not been met. Therefore, we decided that the Plan does not have to pay for the tumor excision services coded as 21930 provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cardiology consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the cardiology consultation. You say that the enrollee needs to see a provider where they are currently staying with family. You say traveling would not be convenient. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the cardiology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 10, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 must 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 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 out of network physician services provided to the enrollee on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete dentures. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.
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, complete or partial dentures are limited to once per arch per 60 months. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on June 1, 2018 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on May 5, 2021.
You asked the Plan to waive the copayment for EKG. You say that this is your primary care physician and there should be no copayment for this visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $30 copayment for in-network EKG.
You have been asked to pay the allowed amount of $21.48, which is less than the $30 copayment for EKG. 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 copayment for an electrocardiogram (EKG) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945).
You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
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 occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound cover, foam dressing (A6209), the non-sterile gauze (A6216), and the non-elastic, conforming bandage (A6446) provided on May 7, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the items provided.
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% of the Plan allowed amount for Medicare-covered durable medical equipment and related supplies.
You have been asked to pay $9.22 (Plan allowed amount of $46.13 x 20% coinsurance) for the durable medical supplies provided. 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 wound cover, foam dressing (A6209), the non-sterile gauze (A6216), and the non-elastic, conforming bandage (A6446) provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D4263), and osseous surgery (D4261), provided by an out-of-network physician on January 28, 2021.
You asked the Plan to pay for a bone replacement graft and osseous surgery. You say that you had this procedure done in June of 2019 and the claim was paid. The Plan denied your request. The Plan says the procedure that was provided is not a Medicare covered service; therefore, the claim has been correctly processed.
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 bone
replacement graft (D4263), and osseous surgery (D4261), provided by an out-of-network physician on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on May 6, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the patient's medical records.
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that the CP must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Specifically, the provided records do not document an attempt to consult with, or a referral from, the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient hospital services provided on September 2, 2020.
You asked the Plan to waive the copay for the services provided. You say that you should not have a copay. The Plan denied your request. The Plan says the copay was correctly applied.
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 copay for each Medicare-covered outpatient hospital service. The file shows you received services at an outpatient hospital facility. You have been asked to pay a $200 copay for the services provided. The services fall 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 copay for the outpatient hospital services provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an osseous surgery (D4260 and D4261), provided on April 9, 2021.
You asked the Plan to pay for an osseous surgery. You say that you are on a limited income and cannot afford this. The Plan denied your request. The Plan says the services that were provided are not a covered benefit; therefore, this claim has been correctly denied.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an osseous surgery (D4260 and D4261), provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), provided by a participating provider on June 21, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you had to go to a new dentist because your nephew is no longer taking care of your teeth. The Plan denied your request. The Plan says that you have already exceeded the frequency limit for a comprehensive oral evaluation.
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. The Plan covers a comprehensive oral evaluation when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Evidence was provided that showed a comprehensive evaluation was provided on December 3, 2020. This means that you have exhausted the Plan benefit limit for comprehensive
oral evaluations in 2021. This claim has been correctly denied. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), provided by a participating provider on June 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 3, 2021.
You asked the Plan to waive the copayment for emergency room visit. You say that you are dissatisfied with the care you received and refuse to pay a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $110 copayment for emergency room visit. You have been asked to pay $110 copayment for emergency room visit. Emergency room 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 emergency room visit provided on April 3, 2021.
Your complaint regarding your experience with this emergency room visit 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.