Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost-sharing charges for a SNF stay. We decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.   You asked the Plan to reduce the cost-sharing charges for a SNF stay. You say that the enrollee already pays high charges each a month and you disagree with the claims being reprocessed 9 months later. The Plan says that the claims were processed correctly and the enrollee is being charged the correct amount.  We decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $1,500 to $1,400.   The Plan contract says that enrollee's must pay a $0 copayment for days 1-20, and a $100 copayment for days 21-100 for SNF care.  The enrollee had a SNF stay from November 27, 2020, to December 31, 2020. The Plan says that the enrollee must pay a $100 copayment for 15 SNF days. However, the enrollee cannot be charged a copayment for the day that they are discharged. The Plan did not provide any documentation showing that the enrollee was discharged on a later date nor that there were prior SNF stays within the same benefit period. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $1,500 to $1,400.  We also decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.    The Plan contract says that enrollee's must pay a $0 copayment for days 1-20, and a $100 copayment for days 21-100 for SNF care.  The enrollee had a SNF stay from November 27, 2020, to December 31, 2020. The enrollee is not being charged a copayment for days 1-20 (November 27, 2020, to December 16, 2020). The enrollee is responsible to pay a $100 copayment for days 21-34 (December 17, 2020, to December 30, 2020). The total amount the enrollee owes is: $100 (copayment) x 14 (SNF days) = $1,400 Therefore, we decided that the Plan does not have to waive the $1,400 copayment for a SNF stay.  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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit (99281) provided on August 13, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered in full as you did not want to go in the first place and they didn't even tend to your wounds. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 a $54.80 copayment for an emergency room visit, which is less than the $90 stated in the Plan's contract. Emergency room visits fall 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 an emergency room visit (99281) provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on October 4, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on August 17, 2021.  You asked the Plan to waive the copayment for laboratory services. You say that the services should be considered preventative. 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 $20 copayment for laboratory services.   You have been asked to pay the allowed amount of $17.18, which is less than the $20 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the requirements for approval.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 11, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that the services provided were rendered at Wellspan Surgery Center. The Plan denied your request. The Plan says services provided were rendered in an outpatient hospital facility and the proper copayment was applied.  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 visit, per provider, per day for surgery performed in an outpatient hospital setting.     You have been asked to pay a $350 copayment for the outpatient surgery. The outpatient surgery 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 outpatient surgery provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction of premalignant lesions (17110, 17004) provided on September 20, 2021.

You asked the Plan to waive the copayment for the destruction of premalignant lesions. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $300 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $300 copayment for the destruction of premalignant lesions. The destruction of premalignant lesions fall 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 the destruction of premalignant lesions (17110, 17004) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on September 7, 2021.

You asked the Plan to pay for an eye refraction. You say that you usually get your eye exam during the warm weather because your ophthalmologist is an hour away and you want to avoid driving in winter. You say that you postponed your usual "warm weather" 2020 exam because of Coronavirus and then had it done on November 12, 2020, and when you received the exam in September 2021 it was to get back to your preferred schedule so that it will not result in more than one exam a year and that your next exam is scheduled for September 2022. The Plan denied your request. The Plan says you have exceeded the limits set in the subscriber agreement. The service is covered once every 12 months and per the member's claim history, payment was issued for service 92015 billed for November 12, 2020, which is within the 12-month limit.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions every 12 months.

We looked at the file and the Plan's rules. The file shows that the service is covered once every 12 months and per your claim history, the Plan issued payment for the eye refraction billed for November 12, 2020, which is within the 12-month limit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on June 2, 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 laboratory service (88305) rendered by the out-of-network (OON) provider on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 4, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services were not referred by a 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 imaging services provided to the enrollee on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on October 6, 2021.  You asked the Plan to pay for the partial denture. You say that you were advised that your dentist never sent a pre-estimate for the services you received. The Plan denied your request. The Plan says the partial denture with flexible base is not listed as a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the physical therapy services provided on November 3, 2021, through November 17, 2021.  You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration because you were referred to this provider by your in-network surgeon. The Plan denied your request. The Plan says that these services were rendered out-of-network without prior authorization.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the member alleges that they were referred to this out-of-network provider by their in-network surgeon. The Plan has not forwarded this provider's claim to verify how the member was referred for these services. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the physical therapy services provided on November 3, 2021, through November 17, 2021.   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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on March 5, 2021.  You asked the Plan to waive the copayment for emergency care. You say that due to the quality of care you received 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 $90 copayment for emergency care.   You have been asked to pay a $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 March 5, 2021.  Your quality of care concerns have been handled separately by the Plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided on November 18, 2021, by an out-of-network provider.  

You asked the Plan to pay for psychotherapy services. You say that you have been seeing the provider for more than 20 years and you want to continue. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  

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 psychotherapy services provided on November 18, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transurethral electrosurgical resection of the prostate provided on July 21, 2021, to July 22, 2021.

You asked the Plan to waive the coinsurance for the transurethral electrosurgical resection of the prostate. You say that you disagree with how the surgery was coded because you were kept in the hospital overnight. 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 20% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

The medical records show that you received the transurethral electrosurgical resection of the prostate at an outpatient hospital facility from July 21, 2021, to July 22, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $3,451.67 and 20% of that is $862.92. 

You have been asked to pay the total coinsurance amount of $862.92 for the transurethral electrosurgical resection of the prostate. The transurethral electrosurgical resection of the prostate falls within the outpatient surgery and other medical 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 coinsurance for the transurethral electrosurgical resection of the prostate provided on July 21, 2021, to July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vaccine administration service rendered by the out-of-network (OON) provider on September 30, 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 vaccine administration service rendered by the out-of-network (OON) provider on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on March 11, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you did not have a copayment before. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $40 copayment for Physician/Practitioner services, including doctor's office visits.       You have been asked to pay a $40 copayment for an in-person specialist office visit. Follow up visits are not fully covered by the Plan, which is why you have a copayment now and not before. Specialist office visits 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 copayment for a specialist office visit (99213) provided on March 11, 2021.