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

We decided that the Plan does not have to pay for the x-ray coded 74018 provided on May 29, 2021.

You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services were billed incorrectly.

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, the CPT Code Manual definition of code 74018 is radiologic examination, abdomen; 1 view.

We find that CPT code 74018 is not supported in the medical record. Specifically, this code was billed with an
inappropriate place of service. The services were billed with place of service 22 (outpatient); however, the
documentation shows that the enrollee was inpatient during this date of service. Based on this information, we
decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan
does not have to pay for the x-ray coded 74018 provided on May 29, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Evenity. Our reviewer says that the requirements for coverage of Evenity have not been met. Our physician reviewer found the Plan requires a trial of drug Forteo or Tymlos before they will approve the requested drug. The provided records do not indicate that the enrollee has tried and failed Forteo or Tymlos, that these drugs would be less effective, or that they would have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for positive airway pressure (PAP) accessories and supplies (A4604, A7030, A7031, A7035, A7038) provided on June 10, 2021.

You asked the Plan to waive the coinsurance for oxygen equipment. You say that the cost-share is improper and to pay any amount on the claim would be perjurious. The Plan denied your request. The Plan says the claim was 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 Durable Medical Equipment (DME) and Related Supplies. 

You have been asked to pay a 20% coinsurance for oxygen equipment, which falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for positive airway pressure (PAP) accessories and supplies (A4604, A7030, A7031, A7035, A7038) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the eyeglasses (V2020, V2203) provided on June 7, 2021.

You asked the Plan to reduce the cost share for the eyeglasses. You say that you were charged too much for your glasses and should only have a $10 copayment. The Plan denied your request. The Plan says your benefits were applied correctly, and you were charged the $10 copayment plus the amount that exceeds the Plan's $125 benefit maximum.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $125 for routine eyeglasses or contact lenses every year. You will be responsible for a $10 copayment and any amount over the Plan's benefit maximum total retail cost of $125.

We looked at the file and the Plan's rules. Documentation shows that the total cost for the eyeglasses was $149.91. A discount of $3.74 was applied, bringing the total cost to $146.17. The Plan paid $125, and you are responsible for your $10 copayment and the remaining cost of the glasses which exceeds the benefit allowance of $125. ($146.17 - $125 = $21.17. $21.17 + $10 copayment = $31.17). The receipt provided for review shows that you paid $31.17 at the time of service. This means 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 reduce the cost share for the eyeglasses (V2020, V2203) provided on June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided form April 30, 2021, to May 12, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the charges are due to a medical error that left you bleeding out and you should not be responsible for the 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 $215 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from April 30, 2021, to May 12, 2021. Therefore, you are responsible to pay a $215 copayment for days 1-7 (April 30, 2021, to May 6, 2021). The total amount you owe is: $215 (copayment) x 7 (inpatient days) = $1,505. You have been asked to pay the total copayment amount of $1,505 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided form April 30, 2021, to May 12, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5060) provided on March 7, 2021.

You asked the Plan to pay for hearing aids. You say that you were not aware that hearing services had to be obtained through a company in the United States. The Plan denied your request. The Plan says rules for payment have not been met.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from a contracted provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items in question were obtained from a provider not contracted with the Plan. Therefore, we decided that the Plan does not have to pay for hearing aids (V5060) provided on March 7, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out of network (OON) oral surgeon.

You asked the Plan to pre-approve the OON oral surgeon services. You say that you prefer the requested OON doctor because he is medically qualified with extensive experience. The Plan denied your request. The Plan says there is not a network deficiency and the services needed are available from a contracted 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 covered services are limited to those performed by a provider in the Plan's dental vendor network only. In this case, you are requesting coverage from an oral surgeon who is not within the Plan's dental vendor network. Therefore, we decided that the Plan does not have to pre-approve services with an out of network (OON) oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab tests. You say that the services were rendered to the enrollee and need to be reimbursed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 laboratory testing provided on June 30, 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 office visit (99203) provided July 2, 2021.

You asked the Plan to pay for the office visit. You say that any medical procedures done in the month of June 2021 should be billed and paid for by the Plan. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospitalization services provided from October 26, 2020, to October 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the inpatient hospitalization services. The Plan denied your request. The Plan says these services were referred and rendered by non-participating providers.

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. Therefore, we decided that the Plan does not have to pay for the inpatient hospitalizatio
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on
March 3, 2021, by an OON provider.
You asked the Plan to pay for the psychotherapy services. You say that you have been seeing the enrollee via
telehealth since 12/03/2020. You are appealing the decision to deny reimbursement. The enrollee is autistic and
would have a difficult time transitioning to another therapist. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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 individual psychotherapy services (90837)
provided on March 3, 2021, by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110) and unspecified preventative procedure (D1999) provided on May 4, 2021.

You asked the Plan to pay for the dental care. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says dental care is excluded from coverage under Medicare. The Plan offers an optional supplemental (extra) dental benefit for an additional premium, but there is no record that you are enrolled in this benefit or have paid this premium.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110) and unspecified preventative procedure (D1999) provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 26, 2020.

You asked the Plan to pay for the services provided. You say that the test is used for clinical purposes. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

The claim shows a place of service billed as an independent laboratory. The records provided do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network
provider.

You asked the Plan to pre-approve the referral. You say that you lost your eye due to the plan prescribing an
incorrect medication. The Plan denied your request. The Plan says you are contractually required to obtain
services from network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral for a second opinion with an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on July 7, 2021.

You asked the Plan to waive the copayment for an EGD. You say that you were never informed that you would owe a copayment. 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 $375 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You received an EGD on July 7, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $375 copayment.

You have been asked to pay a $375 copayment for an EGD. An EGD 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 an EGD provided on July 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided between 10PM and 8AM at a 24-hour facility (99053) provided on June 29, 2021.

You asked the Plan to pay for medical services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is always bundled for payment and no separate payment is ever made.

The Plan must follow Medicare rules. Medicare rules say that code 99053 is always bundled for payment, and if it is covered payment is subsumed into the payment for the services to which it is incident. 

We looked at the file and Medicare rules. This code is always bundled for payment, so no separate payment is made. Based on this information, we decided that Medicare rules for coverage of medical services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided between 10PM and 8AM at a 24-hour facility (99053) provided on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from April 24, 2020, to
August 11, 2020.

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 speech language therapy must be billed in
increments of 15 minutes with code G0153.

We looked at the file and Medicare rules. The file shows that the services were not billed with the required
G0153 code. Therefore, we decided that the Plan does not have to pay for the home health services rendered
from April 24, 2020, to August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the customized fabricated abutment (D6057) and implant supported crown (D6065) provided from November 6, 2020, to November 18, 2020.

You asked the Plan to reimburse you for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says there is an annual benefit of $410 for preventive and comprehensive dental services. The Plan also says that the annual benefit 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. The Plan covers the dental services when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the annual benefit has been exceeded. The record shows that the Plan paid $410 towards dental services that you received on July 16, 2020. Therefore, we decided that the Plan does not have to reimburse you for the customized fabricated abutment (D6057) and implant supported crown (D6065) provided from November 6, 2020, to November 18, 2020.