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

We decided that the Plan does not have to pre-approve a DaT scan.
You asked the Plan to pre-approve a DaT scan. You say that the DaT scan is medically necessary to differentiate Parkinson's disease from non-Parkinson's movement disorder. The Plan denied your request. The Plan says based on the Medicare rules your request for a DaT scan for Parkinson's disease is not a covered benefit because the documentation does not support diagnostic criteria for both AD and FTD.
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 a DaT scan. Our reviewer says that a DaT scan is not medically reasonable and necessary. Our physician reviewer found that according to the current diagnostic criteria for Parkinson's Disease (PD) from the Movement Disorders Society: "Ancillary Diagnostic Testing: Currently, PD diagnoses are generally made clinically, and the MDS criteria were designed to be broadly applicable without need for ancillary diagnostic testing." The guidelines otherwise state that "Note that although dopaminergic neuroimaging can help distinguish parkinsonism (ie, degeneration of the nigrostriatal system) from PD-mimics without parkinsonism (eg, essential tremor), it does not qualify as a criterion for the differentiation of PD from other parkinsonian conditions like atypical parkinsonian syndromes"
In this context, given that the official professional society guidelines do not readily indicate that this service is necessary for the diagnosis of PD or management of patients it cannot be determined to otherwise be medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a DaT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a DaT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you from June 17, 2020, to June 24, 2020.
You asked the Plan to pay for the services. You say that you want your health insurance to cover this. The Plan denied your request. The Plan says this should be billed to the auto insurer.
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 directed the
provider to bill the auto insurer as the primary insurer. 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 the services provided to you from June 17, 2020, to June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1,
2020, to December 28, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you had to quarantine for the
coronavirus due to the facilities negligence. 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 $0
copayment for days 1-20 and a $160 copayment for days 21-100 for SNF care.
You had a SNF stay from November 24, 2020, to December 28, 2020. You are not being charged a copayment
for days 1-20 (November 24, 2020, to December 13, 2020). You are responsible to pay a $160 copayment for
days 21-34 (December 14, 2020, to December 27, 2020). The total amount you owe is: $160 (copayment) x 14
(SNF days) = $2,240.
You have been asked to pay the total copayment amount of $2,240 for a SNF stay. A SNF stay falls within the
SNF 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 a SNF stay provided from
December 1, 2020, to December 28, 2020.
Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit
Maximus to make a decision on this type of complaint.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070) rendered by the out-of-network (OON) provider on June 3, 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 transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0070) rendered by the out-of-network (OON) provider on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for the finger splint (L3933) provided on June 23, 2021.
You asked the Plan to hold you harmless for the finger splint. You say that you would like reconsideration because you required the custom finger splint to treat an acute fracture. The Plan denied your request. The Plan says that this claim was not billed with an appropriate place of service code.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the finger splint by a contract provider. The file does not show that the Plan provided notice that the finger splint would not be covered. Under Medicare rules, this means the finger splint is considered approved by the Plan. Additionally, the Plan has confirmed that there is no member responsibility for this claim. Therefore, we decided that the Plan has to hold you harmless for the finger splint (L3933) provided on June 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 3, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER for arm pain, but they did not address that. You don't believe you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for emergency services.
You have been asked to pay a $75 copayment for the ER visit. This copayment applies regardless of your satisfaction with the services received. 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 emergency room (ER) visit you had on July 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service provided on March 4, 2021.
You asked the Plan to pay for the anesthesia. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the anesthesia service provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May 12, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were taken by ambulance to the nearest hospital for an emergency. After you were stabilized, you were transported to a plan facility for admission. You do not believe you should have to pay the copayment for the ambulance transfer between the hospitals. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment per trip for ambulance services. You have been asked to pay a $150 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on May 12, 2021.
Please note that our decision is limited to the issue of the copayment charged for the ambulance services. If you wish to appeal anything else (such as the emergency room visit), please contact the Plan directly to start that process.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection procedure you had at an ambulatory surgical center on March 8, 2021.
You asked the Plan to waive the copayment for the epidural injection procedure. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery in an ambulatory surgical facility. You have been asked to pay a $350 copayment for the epidural injection procedure. The epidural injection procedure falls within the outpatient surgery in an ambulatory surgical facility 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 epidural injection procedure you had at an ambulatory surgical center on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic sigmoidoscopy you had at an ambulatory surgical facility on June 17, 2020.
You asked the Plan to waive the copayment for the diagnostic sigmoidoscopy. You say that this was your first colonoscopy and you are not supposed to have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that at the time of this service, you only had $112.55 remaining on your out-of-pocket maximum. That is why you were charged that amount for this service instead of the full copayment.
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 surgery in an ambulatory surgical facility.
You have been asked to pay a $225 copayment for the diagnostic sigmoidoscopy. Records show that this service was not performed for screening purposes, but rather to evaluate you for complaints of rectal bleeding. That is why the diagnostic sigmoidoscopy falls within the outpatient surgery in an ambulatory surgical facility 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 diagnostic sigmoidoscopy you had at an ambulatory surgical facility on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series of radiographic images (D0210), provided on May 4, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of radiographic images. You say that the services should be covered. The Plan denied your request. The Plan says supplemental dental services are not covered when obtained out-of-network.
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.
Specifically, you received services through an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series of radiographic images (D0210), provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 2, 2020.
You asked the Plan to pay for the dental service. You say that the services were rendered to treat a medical issue stemming from the medication that he is taking for his cancer diagnosis. You also say that you feel that the claim should be processed under your medical benefit. The Plan denied your request. The Plan says the
Benefit Bank has a benefit maximum of $500. The Plan also says that the Benefit Bank benefit has been exhausted.
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. Additionally, the file shows that the Benefit Bank maximum has been exhausted. The file shows that you used $99 for services received on January 20, 2020, $400 for services received on February 27, 2020, and $1 towards the date of service in this case. $99 + $400 + $1 = $500. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 13, 2021.
You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.
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 and the services is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on May 12, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 13, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was your annual physician and you saw a nurse practitioner instead of the physician and you disagree with the specialist charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist visits. The record shows that you had an office visit with a specialist on October 13, 2020. Therefore, you are responsible to pay the $30 copayment for specialist services. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits you had with a pulmonologist on July 1, 2021, and July 2, 2021.
You asked the Plan to waive the copayments for the pulmonology visits. You say that you should not have to pay these amounts because you were an inpatient in the hospital. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that it reached out to the provider and the provider confirmed you were not an inpatient at the time of these services.
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 $45 copayment for visits with a specialist. You have been asked to pay a $45 copayment for the pulmonology visits. The pulmonology visits fall within the visits with a specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visits you had with a pulmonologist on July 1, 2021, and July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 2, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says periodic oral exam is covered once every 6 months. The Plan says that prophylaxis is covered once every 6 months. The Plan also says that the frequency limits have been exceeded.
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for an oral evaluation and prophylaxis that you received on January 28, 2021, less than 6 months before. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the septal bridle procedure provided on June 17, 2021.
You asked the Plan to pay for the services provided. You say that the procedure is done for those who are at risk to pull their feeding tube out. The Plan denied your request. The Plan says this procedure is not identified separately.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.
We find that this service at issue was provided via arrangement of the facility. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the septal bridle procedure provided on June 17, 2021.