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

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and to pay more for the comprehensive oral evaluation (D0150) provided on May 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the panoramic x-ray or pay more for the comprehensive oral evaluation. You say that you would like to appeal these services. The Plan denied your request. The Plan says the panoramic x-ray is not a covered service. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, panoramic x-ray (D0330) is not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for the comprehensive oral evaluation (D0150) plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and to pay more for the comprehensive oral evaluation (D0150) provided on May 17, 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 services provided by an out-of-network provider on June 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 requested 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 services provided by an out-of-network provider on June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services
provided from April 21, 2021, to May 2, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you would
like the Plan to reconsider your request. The Plan denied your request. The Plan says you received inpatient
rehabilitation services on the dates of service at issue in this appeal. The Plan says that the correct copayment
has applied per your contract with the Plan.
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 $275
copayment per day for days 1-5 for Acute rehabilitation services.
We looked at the file, the Plan's contract, and Medicare rules. The file shows that you received inpatient
rehabilitation services from April 21, 2021, to May 2, 2021. You have been asked to pay a $275 copayment per
day for days 1-5 for the inpatient rehabilitation services, totaling $1375. The inpatient rehabilitation services
fall within the Acute rehabilitation services benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the inpatient rehabilitation services provided from April 21, 2021, to May 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says this medicine will be shipped by a pharmacy to your provider.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: Favorable

We decided that the Plan has to pay for the hemodialysis (HD) services provided from March 18, 2021,
through April 6, 2021.
You asked the Plan to pay for the HD services. You say that this was billed with a diagnosis of acute kidney
injury. Medicare now allows payment for HD for this diagnosis. The Plan denied your request. The Plan says
that payment is not allowed for this End-Stage-Renal Disease Treatment Facility claim because it contains
invalid data or is missing data like the condition code which is required per Centers for Medicare and Medicaid
Services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has failed to provide a cogent denial rationale in this case. The Plan's
rationale is simply that there is invalid or missing data on the claim. For Maximus to uphold a Plan's denial, we
must be able to confirm that the reason for denial is correct. It is not within our scope to review an entire claim
to identify what may be missing or invalid. Without a specific issue identified by the Plan which can be
confirmed, we find that the Plan has not done its due diligence and has not supported this denial of payment.
Therefore, we decided that the Plan has to pay for the hemodialysis (HD) services provided from March 18,
2021, through April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provide don June 16, 2021.
You asked the Plan to pay for the dental service. You say that the receptionist at the office told you that the service is covered by your insurance. You also say that you were at the mercy of the provider and believe that your insurance would cover the payment. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.
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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provide don June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from June 2, 2021, through June 7, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee should only be billed for three (3) days and it is the error of the hospital since no one ever called you to pick up the enrollee the day they were ready. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee's 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file shows that the enrollee was admitted on June 2, 2021, and discharged on June 7, 2021. The enrollee was asked to pay a $200 copayment per day from June 1, 2021, through June 6, 2021, days 1-5 of the enrollee's inpatient hospital care. The enrollee was discharged on June 7, 2021, and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $200 copayment per day required for days 1-5. 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 inpatient hospital care provided to the enrollee from June 2, 2021, through June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two x-rays of the spine you had on April 27, 2021.
You asked the Plan to waive the copayment for the two x-rays. You say that you should only be responsible for one of the $15 copayments for the x-rays. The Plan denied your request. The Plan says you had two separate x-rays, so two separate copayments apply.
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 $15 copayment for each for standard x-ray service. You have been asked to pay a $15 copayment for each of the two x-rays. This copayment is a per-service copayment.
You had two x-rays, so two x-ray copayments apply. 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 two x-rays of the spine you had on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care following the elective surgery is medically necessary. The Plan denied your request. The Plan says the criteria for inpatient hospital care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the procedure is not approved for an inpatient admission and can be done as an outpatient / observation stay. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs you received while in outpatient observation at the hospital from May 26, 2021, to May 28, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were medically necessary and you would not have gone to the hospital if you had known you would be charged so much for your care. The Plan denied your request. The Plan says these drugs are not covered under your medical benefits.
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 pay for the self-administered drugs you received while in outpatient observation at the hospital from May 26, 2021, to May 28, 2021.
Benefits for the self-administered drugs 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: 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 you are continuing to decline and an IRF is the best option for your recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 with your current medical stability, there is no need for physician supervision at least
three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. Based upon your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. You do need physical and occupational therapy, but these may be provided safely and effectively at a lower intensity level. IRF admission is not medically necessary; your needs can be met in an alternate setting. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 26, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 70450 was billed with code 70496. Code 70450 may be eligible for payment when billed with this code pair. However, the claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument (CPT code 96127) provided on June 17, 2021.
You asked the Plan to waive the copayment for the diagnostic testing. You say that you have never been billed for this before and do not want this on your record. The Plan denied your request. The Plan says there were no claims found in their system with this same procedure.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that a brief assessment was rendered on June 17, 2021, was rendered your annual physical. Per your 2021 EOC states that you pay $0 for an annual physical. If you receive services that address a medical condition during the same office visit, additional cost-share may apply. The Medicare-allowed amount for the diagnostic testing is less than the set $10 copayment; therefore, you have been asked to pay the lesser amount of $5.11 for the service. 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 brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument (CPT code 96127) provided on June 17, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on July 6, 2021.
You asked the Plan to waive the copayment for the canalith repositioning therapy service. You say that you were already charged a copayment for physical therapy on this date, and that copayment should include this service. The Plan denied your request. The Plan says that you were charged two separate copayments correctly. The Plan says that this service is considered a specialist service, so separate cost sharing applies.
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 says that you pay a $20 copayment per visit for physical therapy services. If the same service type is performed at the same session, only one copayment will apply.
We looked at your contract with the Plan. We also looked at the bill for these services. According to the bill, you had both a physical therapy visit and a canalith repositioning therapy service. Both services were performed by a physical therapist and both are considered outpatient rehabilitation services. A reasonable enrollee would expect that only one copayment would apply in this case, since all services were performed on the same day by the same provider type (i.e., a physical therapist.) It is not reasonable for the Plan to charge a separate copayment for the canalith repositioning therapy service based on this information. The contract does not spell out that a separate cost sharing amount would apply for this service by a physical therapist. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core buildup for tooth #11.
You asked the Plan to pre-approve a core buildup. You say that you are in pain. The Plan denied your request. The Plan says the service is not covered.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core buildup for tooth #11.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 16, 2021.
You asked the Plan to waive the copayment for these services. You say that you were told the provider was in-network. The Plan denied your request. The Plan says the copayment was 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 $55 copayment for each out-of-network Medicare-covered specialist visit.
Review of the file shows that you received out-of-network specialist services on June 16, 2021. You have been asked to pay a $55 copayment for these services. These services fall within the each out-of-network Medicare-covered specialist visit 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.
The file shows that you paid $50 towards these services and are now being asked to pay the $5 remaining balance of the $55 copayment. The Plan viewed your call records and could find no record of a call in which you were told that this provider was in-network. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for progressive lenses (V2781) and photochromatic tint (V2744) provided on February 18, 2021.
You asked the Plan to waive the copayment for progressive lenses (V2781) and photochromatic tint (V2744). The Plan denied your request. The Plan says the member is responsible for a $30 copayment for each covered upgraded service.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan's routine eyewear benefit covers clear plastic standard progressive lenses and plastic photochromatic lenses with a $30 copayment. Therefore, we decided that the Plan does not have to waive the copayment for progressive lenses (V2781) and photochromatic tint (V2744) provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (L3332, L4361, S9999) purchased June 8, 2021, from a provider not contracted with Medicare.
You asked the Plan to pay for the durable medical equipment. You say that these items were medically necessary. The Plan denied your request. The Plan says equipment purchased from a provider not contracted with Medicare is not covered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L3332, L4361, S9999) purchased June 8, 2021, from a provider not contracted with Medicare.