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

We decided that the Plan does not have to waive the copayment for an office visit provided on June 16, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because you only had a urine test and did not see a physician. 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 $10 copayment for primary care doctor visits. The medical records show that you had an office visit on June 16, 2021. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office 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 an office visit provided on June 16, 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 August 20, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that this should be considered a preventative service. 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 $35 copayment for each specialist visit.
You have been asked to pay a $35 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 August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy services coded 58662 provided on March 17,
2021.
You asked the Plan to pay for the laparoscopy services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 58662 is laparoscopy, surgical; with fulguration or
excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method.
We find that CPT code 58662 is not supported in the medical record. Specifically, this code is included in code 58548; therefore, it cannot be separately reimbursed. While this code was billed with modifier 59, the records received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. Based on this information, we decided that Medicare rules for coverage of the laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services coded 58662 provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on August 24, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you are entitled to one free routine eye exam per year. The Plan denied your request. The Plan says this was not a routine eye exam, so the copayment 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 clearly says that you must pay a $20 copayment for medical eye exams. You have been asked to pay a $20 copayment for the medical eye exam. We looked at the medical records from this date of service to determine the type of service you received. The records show that you were evaluated for tired, blurry eyes with a history of macular scarring.
These are medical conditions that are beyond the scope of a routine eye exam. That is why this was a medical, not routine eye exam. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical eye exam you had on August 24, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380) provided on August 31, 2021.
You asked the Plan to waive the copayment for the colonoscopy services. You say that this service was supposed to be a routine screening. You feel that polyps should be part of a routine screening since that is why a screening is performed, and this should be reprocessed with a $0 copayment. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with your contract. The provided colonoscopy included a biopsy; therefore, this was a diagnostic service which is classified as outpatient surgery.
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 $550 copayment for outpatient surgery services. You have been asked to pay a $550 copayment for the colonoscopy services. The colonoscopy provided on the date in question was billed with code 45380 and included a biopsy service. Code 45380 is classified as outpatient surgery and is not the same as a screening. A screening is provided when there are no symptoms or
issues for which further investigation is needed, and does not include removal of polyps, lesions, or a biopsy. 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 colonoscopy with biopsy (45380) provided on August 31, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for GeneSight testing provided on October 9, 2020.
You asked the Plan to pay for GeneSight testing. You say that the enrollee clearly met criteria for this testing based on the related diagnosis provided by the ordering physician. The Plan denied your request. The Plan says that the denial of payment for this test is correct, because this test is considered investigational.
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan the documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for GeneSight testing provided on October 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4), oral hygiene instructions (D1330), two gingival irrigations (D4921 x2), and two periodontal procedures (D4999 x2) provided on February 17, 2021, and March 22, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images, oral hygiene instructions, gingival irrigations, and periodontal procedures. You say that you paid $691.00 and were not given an alternative treatment that was covered for the cleaning. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you signed a treatment plan on February 17, 2021 acknowledging $0 Plan payment and accepting responsibility for the cost of 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4), oral hygiene instructions (D1330), two gingival irrigations (D4921 x2), and two periodontal procedures (D4999 x2) provided on February 17, 2021, and March 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 2, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were directed to the wrong location. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency care visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows the ultrasound results were discussed during your emergency room visit which means services were performed.
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 visit provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on May 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you tried to order one and were told there would not be one available for a year. The Plan denied your request. The Plan says the item received is not a covered benefit when provided by a non-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three prefabricated abutments (D6056 x3) and mandibular implant/abutment supported removable denture for edentulous arch (D6111) provided on June 30, 2021.
You asked the Plan to pay for the prefabricated abutments and mandibular implant/abutment supported removable denture. You say that you realize the implants were not a covered service, but do not understand why the subsequent denture fabrications are being denied. The Plan denied your request. The Plan says these implant services are not covered benefits under your plan.
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, charges for any type of implant and all related services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the three prefabricated abutments (D6056 x3) and mandibular implant/abutment supported removable denture for edentulous arch (D6111) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on July 12, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on July 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380) provided on August 10, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you did not realize that colonoscopy services would not be covered once you hit a certain age, and you do not feel you should have to pay for this service. The Plan denied your request. The Plan says this service is covered and was process in accordance with your contract. This colonoscopy included a biopsy, and therefore is a diagnostic service which is classified as an outpatient surgical 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). The Plan's contract states that when a screening colonoscopy or sigmoidoscopy becomes a diagnostic procedure (e.g., results in a biopsy or removal of a lesion or growth), then the outpatient surgery cost sharing may apply. Your contract with the Plan clearly says that you must pay a
$225 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
Documentation shows that this service is covered by the Plan. The provider charged $1,125 for the colonoscopy with biopsy. The Plan's allowed amount for this service (the discounted rate) is $484.You have been asked to pay a $225 copayment for the colonoscopy, and the Plan has covered the remaining cost. A screening colonoscopy is provided when there is no cause for concern and no symptoms or issues to investigate or that require further investigation. Because this colonoscopy involved a biopsy, it is not considered a screening and falls within the outpatient surgical 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 colonoscopy with biopsy (45380) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81546) provided on May 26, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized.
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 service 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 lab services (81546) provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 2021.
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that procedure code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 3, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you waited over 5 hours and ended up leaving before completing the visit. You state that you never received the test results. 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 $90 copayment for emergency care. You have been asked to pay the allowed amount of $56.76, which is less than the $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on September 3, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist services provided on February 16, 2021.
You asked the Plan to waive the coinsurance for specialist services. You say that the procedure was necessary and you disagree with the out-of-network 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 40% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. The record shows that you received out-of-network specialist services on February 16, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $378.57 and 40% of that is $151.43.
You have been asked to pay the total coinsurance amount of $151.43 for specialist services. Specialist services fall 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 coinsurance for specialist services provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and incomplete root canal (D3332) provided on July 29, 2021.
You asked the Plan to reimburse you for the dental services. You say that you were trying to save your tooth by getting a root canal. You say that a root canal could not be completed. You say that the crack preventing the root canal from being completed was not found until the procedure was partially done. You also say that insurance always seems to find a reason to not pay. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that incomplete root canal 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. 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 frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on April 8, 2021, and July 26, 2021. Additionally, incomplete root canal is not listed as a covered service. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and incomplete root canal (D3332) provided on July 29, 2021.