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

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on August 10, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you were not told this provider was out-of-network and you feel you should not be responsible for these charges. The Plan denied your request. The Plan says this provider is out-of-network, and this claim was processed in accordance with your contract. The record shows that you did not contact the Plan prior to services to confirm 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. Your contract with the Plan clearly says that you must pay 50% coinsurance for dental cleanings and periodic oral exams received from out-of-network providers. In addition, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. 

The provider billed the Plan a total of $155 for the dental cleaning and periodic oral exam provided on August 10, 2021. The Plan's allowed amount for both services combined comes to $79. This is the amount that an in-network provider would accept as full payment for these services, but out-of-network providers do not have this agreement and are allowed to bill you the difference between the Plan's price and the billed amount ($155 - $79 = $76). In addition, you are responsible for 50% coinsurance of the Plan's allowed amount for these services when they are received out-of-network ($79 x 50% = $39.50). You have been asked to pay $115.50 for these services ($76 + $39.50 = $115.50). 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 pay any additional amount for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on August 10, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2391) provided on September 27, 2021.

You asked the Plan to pay for the resin-based composites. You say that you did not know, nor did you give permission, for additional procedures not covered at the time and you feel you should not be held responsible for the additional cost. The Plan denied your request. The Plan says your benefits for this service had been satisfied and the frequency limitation had been exceeded. The Plan also says that when you contacted the Plan you did not verify benefits for restorations but were advised that the Plan is code specific, and limitations apply.

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, restorations (fillings) are limited to two procedure codes per calendar year. The record shows that you received two resin-based composites (D2391 x2) on September 22, 2021 and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2391) provided on September 27, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from August 12, 2021, to August 13, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you did not receive a stress test and nothing was really done to treat your condition. 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 $225 copayment for outpatient hospital observation.   You have been asked to pay a $225 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from August 12, 2021, to August 13, 2021.   Your quality of care concerns have been handled separately by the Plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the removable foot arch supports (L3040, L3060) rendered by the out-of-network (OON) provider on August 30, 2021.  You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items 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 items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to issue reimbursement for the removable foot arch supports (L3040, L3060) rendered by the out-of-network (OON) provider on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 9, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you contacted the dentist because you were in extreme pain, and he took x-rays. You also say that the dentist told you to see an oral since he could not do anything because you were in such extreme pain. The Plan denied your request. The Plan says the limited oral exam that was performed is not a covered benefit. The Plan also says that you signed a pay agreement with the provider.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve enteral nutrition.  You asked the Plan to pre-approve the services. You say that you do not do well on regular as it upsets your stomach. The Plan denied your request. The Plan says nutritional counseling is recommended, which can help you reach your health goals.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no documentation indicating that your body mass index is less than normal. There has not been a sudden weight loss of more than 10% of body weight. There are no reported problems swallowing, or documentation of the use of a feeding tube. The review has determined that the enrollee does not have either a full or partial non function of the structures that take food to the small bowel, or a disease that impairs digestion and/or absorption of an oral diet. There is no justification in the records for a special formula.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you work with doctor groups who are participating providers. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 referring provider 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 lab services provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient clinic visit services provided on October 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient clinic visit services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 outpatient clinic visit services provided on October 13, 2021 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 office visit (99214) provided on September 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the out-of-network office visit. You say that this physician provides unique care and would be an asset to the Plan's network. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The services in this case were not urgent or emergent, nor were they pre-approved.

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 office visit (99214) provided on September 21, 2021 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 dental cleaning (D1110), periodic oral exam (D0120) and fluoride application (D1208) provided on August 11, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network dental care. You say that you believed you had out-of-network benefits. The Plan denied your request. The Plan says dental services are not covered when they are received from out-of-network providers. The provider in question is not part of the Plan's network. In addition, fluoride is not covered by your dental benefit, regardless of the participation status of the rendering provider.

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 the services listed in the dental benefits section of the contract when they are received through a participating provider.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. In addition, fluoride is not listed as a covered service under your dental benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral exam (D0120) and fluoride application (D1208) provided on August 11, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ostomy pouch (A4425) and the ostomy skin barrier (A4407) rendered by the out-of-network (OON) provider on January 6, 2021.  You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items 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 items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the ostomy pouch (A4425) and the ostomy skin barrier (A4407) rendered by the out-of-network (OON) provider on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 18, 2021, to June 20, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $350 copayment for each of the first five days of an inpatient hospital stay. 

You have been asked to pay a $700 copayment for the two-day inpatient stay ($350 x 2 = $700). 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 hospital admission and services provided from June 18, 2021, to June 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis. You say that you have been with this provider for five years and were not advised that the treating provider was no longer in-network. The Plan denied your request. The Plan says the treating provider is not participating with the Plan. The Plan also says that you did not contact the Plan prior to receiving these services to verify benefits or coverage with the treating provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on October 6, 2021.  You asked the Plan to pay for code 70450. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on July 1, 2021.  You asked the Plan to pay for code 0013M. 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.  The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered.   We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision services provided on September 7, 2021.  You asked the Plan to pay for the services provided. You say that you were supposed to get a free eye exam. The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for each Medicare-covered exam to diagnose and treat disease or conditions of the eye.   The file shows that you received a medical eye exam and ophthalmic biometry testing. You have been asked to pay a 20% coinsurance for the services provided. The services fall within the vision care benefit category.     You also received eye refraction services. Eye refraction is only covered when provided during a routine eye exam, not a medical eye exam. 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 pay for the vision services provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) and the nail debridement (11720) rendered by an out-of-network (OON) provider on September 7, 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.  You are 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 office visit (99203) and the nail debridement (11720) rendered by an out-of-network (OON) provider on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for prostate surgery provided on June 23, 2020.  You asked the Plan to waive the copayment for the prostate surgery. You say that the services should be covered as the surgery was unsuccessful. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 a $295 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.       You have been asked to pay a $295 copayment for prostate surgery. Based on the Plans guidelines, the copayment for this surgery applies regardless of whether it is successful. Prostate surgery 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 prostate surgery provided on June 23, 2020.