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

We decided the Plan does not have to pay for services provided from March 11, 2021, to April 2, 2021.
You asked the Plan for these services. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says these services must be addressed under your Medicaid benefit. Maximus
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that this claim denied under your Medicare benefit because you are Medicaid eligible. The Plan included
documentation to show that you are Medicaid eligible. The Plan says that Medicare pays covered dually
eligible beneficiaries' medical services first, because Medicaid is generally the payer of last resort. Medicaid
may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal
care, and home- and community-based services). These services qualified under the Medicaid coverage.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing and coverage information. Your contract states dual eligible enrollees will have services that are
covered by either Medicare or Medicaid, but not by both. The services provided fall under your Medicaid
coverage and not your Medicare coverage. The IRE does not have jurisdiction over your Medicaid benefits.
Therefore, we decided that the Plan does not have to pay for practitioner services provided from March 11,
2021 to April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network surgery at the in-network rate.
You asked the Plan to pay this cost share at the in-network rate. You say that you called the Plan prior to the
services being rendered and were told that you would only be responsible for the office visit copayment. You
also state that you received services from an out-of-network provider because all in-network providers were
inaccessible. The Plan denied your request. The Plan says this coinsurance was applied correctly. Maximus
overturned the Plans denial due to a lack of phone records in the case file to support this conversation
referenced by the Plan.
The Plan requested a reopen and provided additional information. The Plan notes they denied this request for
application of the in-network rate on prior authorization for these services.
The Plan provided documentation of a phone call with their Customer Service Team and your spouse. The
documentation shows your spouse stated you were "ok" with out-of-network cost-share. It should also be
noted that while it was stated to the Customer Service Team, that this would be an in-office procedure, the
claim was not billed this way by the provider. The claim was billed as an outpatient surgery by the physician.
The logs show the Customer Service Team quoted the benefits based on the information provided by you or
your spouse during the phone call. The Customer Service Team cannot predict what services will be provided,
nor how a claim will be billed after they are rendered. Furthermore, it was also stated you did not want to go to
downtown for these services due to the rioting during that time. The Plan demonstrated there are
several participating dermatologists closer to your residential address, which were outside of the downtown
area.
Based on the new information provided by the Plan, we have now decided the Plan is correct in this case. 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 out of network
services will have a higher cost share. Documentation was presented to show there were network providers
available to you for this treatment. The documentation shows you were denied this request for payment at the
in-network rate on a prior authorization request. The phone log documentation shows that you orally accepted
the out of network cost share estimated. The customer service line notes that all cost sharing information given
is an estimate based on the services quoted and may changed once the service is provided. 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 out of network surgery provided on October 14, 2020, at the in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) and diagnostic consultation
(D9310) provided on November 8, 2021.
You asked the Plan to pay for the dental services. You say that you were assured that this provider was innetwork.
The Plan denied your request. The Plan says the provider in this case is out-of-network. In addition,
the diagnostic consultation is not 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. The Plan does not cover outof-
network dental care. The Plan does not cover services which are not listed in the Plan's contract.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's network. In
addition, while the Plan offers a dental benefit in excess of Medicare coverage, a diagnostic consultation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
surgical extraction (D7210) and diagnostic consultation (D9310) provided on November 8, 2021.
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay reimbursement you for overpayment made for out of network
services provided on June 24, 2020.
You asked the Plan to pay additional reimbursement for services you believe you overpaid the provider for.
The Plan denied your request. The Plan says the Plan pays the Medicare allowable for services rendered. Any
overpayment for services would need to be refunded by the out of network provider. Maximus overturned the
Plans denial. The Plan requested a reopen and states per Medicare guidelines, neither the Plan nor an enrollee
pays for balance billing if a provider accepts Original Medicare.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan gives an explanation regarding balance billing and how to
work with the Plan and the type of provider used regarding overpayment. In this instance, this provider was an
out of network provider who accepts Medicare payment. Any overpayment you made before the claim was
processed and paid by the Plan to the provider should be reimbursed by that provider as they have agreed to
accept the Medicare allowable reduced rate. Therefore, we decided the Plan does not have to reimbursement
you for overpayment made for out of network services provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear purchased on March 22, 2021.
You asked the Plan to pay for eyewear. The Plan denied your request. The Plan says they are only covering
those vision items covered under the Plan benefit. Maximus partially overturned the Plans denial. The Plan
requested a reopen and stated that the items Maximus overturned were already covered.
The Plan is correct in this case. Medicare does not cover routine eyewear. The Plan offers vision coverage that
exceeds Medicare coverage; therefore, the Plans coverage rules apply in this case. The Plan has confirmed that
you are not being held financially responsible for codes V2203 for lenses and code V2750 for anti-reflective
coating. We were already in agreement with the Plan regarding the remaining items denied. Therefore, we
decided that the Plan does not have to pay for codes V2781 (progressive lenses) and V2782 (high index
materials) purchased on March 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on April 17, 2021.
You asked the Plan to pay for the services. You say that you would like additional payment from the secondary insurance. The Plan denied your request. The Plan says the maximum allowed amount minus the enrollee's copayment was paid by the primary insurance provider.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment.
Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has confirmed that the maximum allowed amount for the services was already paid for by the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on January 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the anesthesia. You say that the billed procedure is an Outpatient on Campus location and therefore, prior authorization is not needed. 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 records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for anesthesia provided on January 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $15 copayment for an office visit provided on June 7, 2021.
You asked the Plan to waive this copayment. You say that this was an annual wellness visit and should be no
charge. The Plan denied your request. The Plan says the Plan stated the annual wellness visit was no charge
however your provider billed services that are not covered under the wellness visit which incurred an office
visit copayment. Maximus overturned the Plans denial for a lack of information in the case file. The Plan
requested a reopen and provided additional information to confirm this argument.
The Plan is correct in this case. 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 $15 copayment for a physician visit. The Plan has provided records to show you
are not being charged for the annual wellness visit however you are being charged or those ancillary services
provided by the physician which then qualified for the office visit copayment. 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 $15 copayment for an office visit provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) provided on May 2, 2019.
You asked the Plan to pay for the ambulance services. You say that the medically necessary ambulance transport was provided to the enrollee in good faith. The Plan denied your request. The Plan says the ambulance services were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the ambulance services. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the record indicates that the enrollee was transported from the hospital emergency room to a nursing home. The record indicates that the enrollee was transported via stretcher. The record does not indicate that the enrollee's clinical condition is such that other methods of transport are contraindicated. The elements of the coverage criteria are not satisfied. Therefore, the reviewer found that the ambulance services were not medically reasonable or necessary.
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 ambulance services have not been met. Specifically, the file does not indicate that the enrollee's clinical condition is such that other methods of transport are contraindicated. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and ground mileage (A0425) provided on May 2, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not need three hours a day of therapy, her medical illnesses are stable, and she does not need a physician to monitor them three times a week.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided by an out-of-network provider on November 12, 2021.
You asked the Plan to waive the deductible for the office visit. You say that the provider was in-network, and you should have a $0 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a 30% coinsurance which applies to each covered out-of-network primary care physician (PCP) or specialist visit once you meet the $1,250 yearly deductible. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 30% coinsurance which applies to each covered out-of-network primary care physician (PCP) or specialist visit once you meet the $1,250 yearly deductible. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on November 12, 2021. The record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided by an out-of-network provider on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99326) rendered by the out-of-network (OON) provider on September 14, 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 domiciliary or rest home visit for the evaluation and management of a new patient (99326) rendered by the out-of-network (OON) provider on September 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services identified. You do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on June 8, 2021.
You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that hospice has denied this claim stating that the services are not related to the enrollee's terminal diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on June 8, 2021.