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

We decided that the Plan does not have to pay for a hospital bed, semi-electric and a gel or gel-like pressure 
pad for mattress provided on May 11, 2020. 
 
You asked the Plan to pay for the hospital bed, semi-electric and a gel or gel-like pressure pad for mattress. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the member?s terminal condition. The Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 8, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a hospital bed, semi-electric 
and a gel or gel-like pressure pad for mattress provided on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings, two gingival 
irrigations, and drugs or medicaments dispensed in the office for home use provided. 
 
You asked the Plan to pay for the scalings and planings, gingival irrigations, and drugs or medicaments. You 
say that you thought these services were covered. You also say that the provider never advised you that these 
services would not be covered. The Plan denied your request. The Plan says these 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 two 
periodontal scalings and root planings, two gingival irrigations, and drugs or medicaments dispensed in the 
office for home use provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 30, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 physician services provided on April 30, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an x-ray and ultrasound (Q0092, R0070, 
93306, 71046) provided October 15, 2020 to October 22, 2020. 
 
You asked the Plan to waive the copayments for the x-ray and ultrasound. You say that you were never told 
there would be a copayment. The Plan denied your request. The Plan says the correct 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 an $85 
copayment for Outpatient diagnostic tests.  
 
You have been asked to pay two $85 copayments for the x-ray and ultrasound. The x-ray and ultrasound fall 
within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
an x-ray and ultrasound (Q0092, R0070, 93306, 71046) provided October 15, 2020 to October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first 
intraoral periapical x-ray provided on August 20, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you needed to have an x-ray and exam so the dentist could determine the problem. The Plan 
denied your request. The Plan says these 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 
problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided May 
25, 2020, to June 3, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you believe you are not 
responsible for the copayment due to the service you received. The Plan denied your request. The Plan says the 
copayment applied correctly in this case. 
 
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 $295 
copayment each day for days 1-6 of inpatient hospital care, $0 copayment for additional days for inpatient 
hospital care.  
 
You have been asked to pay a total cost share of $1770 for the inpatient hospital care (6 chargable days x $295 
copayment per day = 1770). The services provided fall 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 the inpatient hospital care provided May 25, 2020, to June 3, 
2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic with a microprocessor knee (L5828, L5845, 
L5848, L5856). 
 
You asked the Plan to pre-approve the prosthetic with a microprocessor knee. You say that the microprocessor 
knee is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic features are only covered when they are 
medically necessary. 
 
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 prosthetic with a microprocessor 
knee. Our reviewer says that the requested microprocessor knee is not medically necessary. Our physician 
reviewer found a K3 prosthetic leg without a computerized knee is available and can help meet the current or 
expected walking needs. The review has determined that the requested Microprocessor feature is not medically 
necessary. 
 
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 prosthetic with a microprocessor knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a prosthetic with a microprocessor knee (L5828, L5845, 
L5848, L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heparin sodium injection coded J1642 provided on July 
6, 2020, to July 11, 2020. 
 
You asked the Plan to pay for the heparin sodium injection. 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 payable. 
 
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 J1642 is injection, heparin sodium, (heparin lock flush), 
per 10 units. 
 
We find that CPT code J1642 is not supported in the medical record. Specifically, this code has a status code of 
"E". A status code of E means that this code is excluded from physician fee schedule by regulation. These 
codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. No 
RVUs or payment amounts are shown, and no payment may be made under the fee schedule for these codes. 
Payment for them, when covered, continues under reasonable charge procedures. Based on this information, we 
decided that Medicare rules for coverage of the heparin sodium injection have not been met. Therefore, we 
decided that the Plan does not have to pay for the heparin sodium injection coded J1642 provided on July 6, 
2020, to July 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of 
intraoral x-rays, and prophylaxis provided by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
prophylaxis. You say that you have been with the same dentist office for more than 40 years. You also say that 
you did not realize that this office was OON. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered 
because your healthcare plan does not have OON benefits. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on March 12, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the enrollee failed to advise you that her 
insurance changed. The Plan denied your request. The Plan says there are participating providers in the 
enrollee's area to choose from. 
 
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 has network providers available 
who can provide physical therapy services. 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 physical therapy services provided on March 12, 2020 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 medical services provided on March 20, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not authorized, the provider that rendered services is 
not in-network with the Plan, the member's primary care physician did not refer for services, the provider that 
did refer for services is not in-network with the Plan and the services were not urgent or emergent. 
 
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 has network providers 
available who can provide 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 medical services provided on March 20, 2020, 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the unspecified preventive service 
(D1999) provided on August 18, 2020. 
 
You asked the Plan to pay the in network rate for the unspecified preventive service. You say that you were 
advised by a plan representative that this dentist was in network. The Plan denied your request. The Plan says 
the unspecified preventive service 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 unspecified preventive service is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in 
network rate for the unspecified preventive service (D1999) provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records do not show an inability to move around without using a 
wheelchair. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is unclear if your mobility deficit significantly interferes with your ability to perform 
MRADLs in the home. It is not clear why a standard manual wheelchair with caregiver assist will not alleviate 
your mobility deficit. The documentation does not reveal that your home provides adequate access and space to 
maneuver the wheelchair. The documentation does not support that you require the lightweight wheelchair to 
perform frequent activities in the home that cannot be performed in a standard wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on August 21, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 has network providers 
available who can provide 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 rest home visit services provided on August 
21, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays provided on September 2, 2020 
and October 14, 2020. 
 
You asked the Plan to waive the copayments for X-rays. You say that you feel that the X-rays should be 
covered as follow-up visits. 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 $40 
copayment for each basic imaging service. 
 
You received an X-ray on September 2, 2020. X-rays are not included in follow-up visits and are subject to 
cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $36.70, which is less than 
the $40 copayment.   
 
You received an X-ray on October 14, 2020. X-rays are not included in follow-up visits and are subject to cost-
sharing charges. Therefore, you are responsible to pay the allowed amount of $36.70, which is less than the $40 
copayment.   
 
The total amount you owe is: $73.40.  
 
You have been asked to pay the total copayment amount of $73.40 for X-rays. X-rays 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 
copayments for X-rays provided on September 2, 2020 and October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 11, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 6, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 11, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on August 27, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were not seen this 
day. The Plan denied your request. The Plan says the correct copayment has been 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 $10 
copayment for physician/practitioner services/primary care physician.  
 
You have been asked to pay a $10 copayment for a specialist office visit. Evidence was provided that showed 
services were provider; therefore, the correct copayment has been applied. A specialist office visit falls within 
the physician/practitioner services/primary care physician 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 provided by a participating provider on August 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the required services can safely be received in a different setting, for example in a 
residential care or home with home health and caregiver support. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the lack of medical records 
available for review, there is no documentation that the enrollee requires skilled nursing or skilled therapy 
services. There is no documentation that this enrollee requires services 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.