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

We decided that the Plan does not have to pay for laboratory services provided on December 11, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory services. 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 laboratory services provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on February 20, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says members of the Plan 
must use in network providers to get medical care and services. The only exceptions are emergencies, urgently 
needed care when the network is not available (generally, when member is out of the area), out-of-area dialysis 
services, and cases in which the Plan authorizes use of out-of-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 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 
drug test. 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 a drug test provided on February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on 
November 24, 2020 and December 8, 2020. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that both claims are part of the 
same procedure. You say that you should not have to pay a second deductible for the same procedure. The Plan 
denied your request. The Plan says the copayments applied 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 $300 
copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital 
facility or ambulatory surgical center. 
 
You have been asked to pay a $300 copayment for each cystourethroscopy. The total amount you owe is $600 
($300/surgery x 2 surgeries = $600). The cystourethroscopy 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 the cystourethroscopy provided on November 24, 2020 and 
December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the teeth cleaning (D1110) and topical fluoride application 
(D1206) provided by an out-of-network provider on November 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you believed this provider was in-network, and 
you called your agent to verify this information. The Plan denied your request. The Plan says they do not cover 
out-of-network care. These services could have been provided in-network. Additionally, the Plan does not have 
a record of a call to verify network status prior to the date of 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, items and services provided out-of-
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the teeth cleaning (D1110) and topical fluoride application (D1206) provided by an out-of-network 
provider on November 23, 2020.  
 
Your complaint about possible misinformation from the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray rendered on November 17, 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 procedure code 73100 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 73100 (wrist x-ray, two views) and 73110 (wrist x-ray, 
three views). Code 73100 is a column II code with a modifier indicator of 1 when billed with column I code 
73110. Code 73100 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the wrist x-ray rendered on November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no 
complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy 
services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the resin-based composite (D2392) 
provided on November 10, 2020. 
 
You asked the Plan to waive the coinsurance for the resin-based composite. You say that you cannot afford this 
coinsurance, and you received a notice that says that all out-of-pocket costs have been eliminated for in-
network services from May through the end of the year due to the pandemic. The Plan denied your request. The 
Plan says that resin-based composites require 50% coinsurance, and the waiver does not apply to all in-network 
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 50% 
coinsurance for resin-based composites.  
 
You have been asked to pay $59.50 for the resin-based composite. The Plan?s allowed amount for this service 
is $119 ($119 x 50% = $59.50). A copy of the notice sent by the Plan was included in your appeal. The notice 
states, ?So, we?ve eliminated all out-of-pocket costs for in-network: primary care visits, outpatient, non-
facility-based behavioral health visits; and telehealth visits.? The service you received is a dental service, which 
does not fall under any of these three categories. 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 resin-based composite (D2392) provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3320) for tooth # 12. 
 
You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says coverage for a root canal is limited to 1 per calendar year, per patient. The 
Plan also says that the frequency limit has been reached. 
 
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 frequency limit of 1 root canal per 
calendar year has been reached. The record shows that the Plan paid for a root canal that the enrollee received 
on January 11, 2021. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) for 
tooth # 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the BiPAP and supplies (A7030, A7035 and 
A7031) provided on November 13, 2020. 
 
You asked the Plan to waive the deductible for the BiPAP and supplies. You say that you would like 
reconsideration because you followed the Plan's instructions when submitting the claim. The Plan denied your 
request. The Plan says you have a deductible of $1000 and at the time of service, you had not reached this 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for Durable Medical Equipment.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible for Durable Medical Equipment. This cost sharing is a contractual obligation that had not 
been met at the time the BiPAP and supplies was received on November 13, 2020. Therefore, we decided that 
the Plan does not have to waive the deductible for the BiPAP and supplies (A7030, A7035 and A7031) 
provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro, Motion G Orthotic device for the enrollee.
You asked the Plan to pre-approve MyoPro, Motion G Orthotic device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a MyoPro Motion G Orthotic device (L8702 - Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated). The Maximus Physician Reviewer determined that the enrollee has an appropriate diagnosis for the requested device which meets Medicare criteria. It was determined that the MyoPro would be considered the standard of care in this situation, as it would be most appropriate and most effective for the enrollee's specific condition. Therefore, the determination was that the enrollee met criteria for the requested item. The Plan argues that no evidence has been presented that the provider has performed a face-to-face or telehealth examination of the enrollee independently or has a doctor-patient relationship with the enrollee. The plan states there is insufficient evidence to assess the safety and/or impact on health outcomes or patient management with this orthosis. The Plan also notes that the signature on the medical records does not match the signature on the Myomo prescription form. Our Medical Director has concluded that the Plan is correct in this case. The physician notes that the enrollee is permanently disabled due to right hemiparesis and aphasia. The note also contains the following under the heading "Neurologic": "Motor - Normal, Gait - Normal." There is no documented need for a MyoPro Motion G Orthotic device in this History & Physical Report. The case file contains a Prescription Form for the L8702 which was signed by the Family Physician on July 20, 2020. The case file also contains a Medical/Orthotic History and Physical Exam Review dated August 5, 2020 by a Physician Consultant who is the Chief Medical Officer of Myomo, Inc. Based on the inconsistency in the records provided, coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro, Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro, Motion G Orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pulp vitality tests (D0460), Re-treatment of previous root canal therapy - molar (D3348) and Post removal (D2955).

You asked the Plan to pay for the pulp vitality tests, retreatment of root canal and post removal. You say that you were told the services would be covered. The Plan denied your request. The Plan says the services are not covered.

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 Pulp vitality tests (D0460), Re-treatment of previous root canal therapy - molar (D3348) and Post removal (D2955).

Your complaint about potentially receiving misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the telehealth visits.

You asked the Plan to waive the copayment for the telehealth visits. You say that all the visits were
telemedicine calls that should be covered. The Plan denied your request. The Plan says that the copayments
applied 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 does not say in clear and accurate terms
how much you should expect to pay for telehealth services billed by a facility.

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay for
telehealth services billed by a facility. The Plan contract does not clearly say how much enrollees must pay for
a facility fee for telehealth visits. This means that the Plan did not follow Medicare rules for disclosure of cost
sharing information. Therefore, we decided that the Plan has to waive the copayment for the telehealth visits.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests.

You asked the Plan to waive the copayment for the laboratory tests. You say that the primary care physician's lab was closed so you had to go to the hospital. You say that the lab work was related to the physical so you should not have to pay. The Plan denied your request. The Plan says the copayment applied 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 $10 for Medicare-covered laboratory tests.

You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Laboratory tests are not included in the annual physical or annual wellness visit benefit. 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 laboratory tests.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to criteria listed in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found the provided documentation contains only conclusory statements regarding the elements of the local coverage determination. No objective information regarding weakness, restriction of mobility, recent injury, or recent surgical procedure is provided. The record is insufficient to establish that a credible patient-physician encounter occurred with an objective assessment. The elements of the local coverage determination are not satisfied.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on November 2, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this 
provider rendered these services under the doctor's supervision. The Plan denied your request. The Plan says 
CPT code 99100 has a status indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99203) provided on October 
19, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have two 
copayments for this date of service. The Plan denied your request. The Plan says this 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 $15 
copayment for each specialist visit.  
 
You have been asked to pay a $15 copayment for an office visit. The record shows that this office visit was 
provided by a different provider than the injection that also processed with a copayment, meaning it is a 
separate specialist visit. 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 (99203) provided 
on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210) and periodontal scaling and root planing (D4342) provided on November 19, 2020 and November 30, 
2020. 
 
You asked the Plan to pay for the dental services. You say that this treatment was necessary, and you feel this 
claim was denied in error. The Plan denied your request. The Plan says the Plan's supplemental dental benefit 
does not offer coverage or payment for services provided outside the Plan's network, and these services were 
provided by an out-of-network 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, services provided outside the Plan?s 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150), intraoral x-rays (D0210) and periodontal scaling and root 
planing (D4342) provided on November 19, 2020 and November 30, 2020.