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

We decided that the Plan does not have to pay for the medical services provided on July 29, 2019 to January
30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because
these services are a covered benefit. The Plan denied your request. The Plan says members are required to
obtain all covered services from network providers when in area and must have prior authorization when not an
emergency.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you must use contracted routine chiropractic providers and prior authorization rules apply.
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 July 29, 2019 to
January 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on July 2, 2018,
December 14, 2018 and April 19, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that the dentist has determined you require
periodontal maintenance due to the osseous surgery and bone replacement graft. The Plan denied your request.
The Plan says the services are not covered 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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
periodontal maintenance provided on July 2, 2018, December 14, 2018 and April 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral feeding supply kit (B4034) and enteral formula,
nutritionally complete, calorically dense (B4152) provided March 9, 2019 to April 7, 2019.
You asked the Plan to pay for the enteral supplies. You say that the records provided should support the
necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the
service billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for enteral feeding supply kit (B4034) and enteral formula,
nutritionally complete, calorically dense (B4152) provided March 9, 2019 to April 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from
January 16, 2020 to January 18, 2020.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you cannot afford 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 20%
coinsurance for inpatient hospital care.
You have been asked to pay $997.37, which is less than the 20% coinsurance for inpatient hospital care.
Inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for inpatient hospital care provided from January 16, 2020 to January 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from
December 31, 2019 through January 2, 2020 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you are appealing
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted to an in-network facility on December 31, 2019 and
discharged on January 2, 2020. You were asked to pay a $318 copayment per day from December 31, 2019
through January 1, 2020, days 1-2 of your inpatient hospital care. You were discharged on January 2, 2020 and
there was no copayment charge for the day of discharge. Per your contract there is a $318 copayment per day
required for days 1-5 for in-network inpatient mental health care. 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 inpatient mental health care from December 31, 2019 through January 2, 2020 provided by an
in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you can't go home at your current state. Your doctor doesn't want you to got to an outside rehab or at home. It would be helpful if you can do the inpatient rehab at the hospital. The Plan denied your request. The Plan says the enrollee does not meet the criteria. Care can be provided safely at a lower level of care such as in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by PMR physician or needs acute rehab nursing care. Functionally given her current level, she does not require IRF level of therapies. The enrollee may benefit from further physical and occupational therapies but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hemodialysis provided from January 2,
2020 to March 31, 2020.
You asked the Plan to waive the coinsurance for hemodialysis. You say that you cannot afford 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 20%
coinsurance for services to treat kidney disease.
You received hemodialysis from January 2, 2020 to March 31, 2020 for a total of 26 services. The allowed
amount per each service is $276 and 20% of that is $55.20. The total amount you owe is: $55.20 (coinsurance)
x 26 (hemodialysis) = $1,435.20.
You have been asked to pay the total coinsurance amount of $1,435.20 for hemodialysis. Hemodialysis falls
within the services to treat kidney disease 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 hemodialysis provided from January 2, 2020 to March 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial upper endoscopy.
You asked the Plan to pre-approve the endoscopy. You say that this is medically necessary. The Plan denied
your request. The Plan says the documentation received fails to indicate that the criteria has been met.
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 endoscopy. Our reviewer says that
the requested services are not medically reasonable or necessary. Our physician reviewer found uncomplicated
epigastric discomfort unrelated to meals and unaccompanied by red flag conditions or signs does not meet
provided coverage criteria for EGD as requested.
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 endoscopy have not been met. Therefore, we decided that the Plan does not
have to pre-approve an initial upper endoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 13, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on August 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on March 3, 2020.
You asked the Plan to waive the copayment for outpatient mental health care. You say that you are unhappy with the care received. 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 outpatient mental health care. You have been asked to pay a $35 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 outpatient mental health care provided on March 3, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injections (J1815) provided on March 9, 2020.
You asked the Plan to pay for the insulin injections. You say that it was necessary to be injected with insulin
during your surgery and recovery time in the hospital because you are a diabetic. You also say that you were
told by the Plan prior to surgery that while an inpatient at a hospital, covered services included drugs and
medications. The Plan denied your request. The Plan says this drug is self-administered and not covered by Part
B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin injections (J1815)
provided on March 9, 2020.
Benefits for insulin injections may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 3, 2020 by a nonparticipating
provider.
You asked the Plan to pay for the dental services. You say that the allowed amount is a mistake. The Plan
denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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.
Review of the file show that you received the dental services on February 3, 2020 provided by a nonparticipating
provider. Your EOC states, "you'll save more when you receive care from one of our in-network
dental providers. You can get care from an out-of-network dental provider but you may pay more." Therefore,
we decided that the Plan does not have to pay for the dental services provided on February 3, 2020 by a nonparticipating
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent ambulance transportation.
You asked the Plan to pre-approve the transportation services. You say that the enrollee cannot tolerate riding
upright in a wheelchair. The Plan denied your request. The Plan says there is no documentation that supports
medical necessity.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 transportation services. Our
physician reviewer found that the enrollee was diagnosed with a spinal cord injury. The documentation does
not support that other means of transport such as a stretcher van would be contraindicated at the date of
transportation. The documentation does not support that she had a life-threatening condition to require the
equipment and trained personnel in the ambulance to justify the ambulance services as transportation.
Therefore, based on the lack of support via the provided documentation, this request for ambulance services
will be considered 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 transportation services have not been met. Therefore, we decided that the
Plan does not have to pre-approve non-emergent ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that you cannot get out of bed by yourself and has to have physical therapy because of chemotherapy. You have to have your bed cranked and you do not have the strength to use the crank. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature, therefore this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from
February 5, 2020 to February 11, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you gave the hospital your
card and this should be covered by insurance. You say you feel you were admitted and should not have to pay
the $275 copayment. The Plan denied your request. The Plan says you have been charged 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 $275
copayment for observation services.
You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the
"Outpatient hospital services" benefit category. The medical record shows you were admitted into observation.
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 observation stay provided from February 5, 2020 to
February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on November 12, 2019.
You asked the Plan to pay for the intraoral x-ray. You say that since the appointment you have had sores. You
say that you are owed over $300. The Plan denied your request. The Plan says one intraoral x-ray is covered
every calendar year.
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 Plan also has a maximum benefit
of one intraoral x-ray per calendar year. The Plan paid for an intraoral x-ray on November 7, 2019, which
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray
provided on November 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided January
18, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you do not feel that you
should have a copay of $250 for an ambulance ride to the hospital when your wife could have driven you to the
hospital. You felt forced to take the ride. The Plan denied your request. The Plan says you were charged this
cost sharing 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 $250
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these
services. 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 ambulance services provided January 18,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) provided on
September 27, 2019.
You asked the Plan to pay for a tetanus and diphtheria toxoids vaccine. You say that this should be covered.
The Plan denied your request. The Plan says this is covered under your Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and
diphtheria toxoids vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a tetanus and
diphtheria toxoids vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus and
diphtheria toxoids vaccine (90714) provided on September 27, 2019.
Benefits for a tetanus and diphtheria toxoids vaccine may be available under Medicare Part D. Contact the Plan
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the coping and core buildup provided on February 13, 2020.
You asked the Plan to pay for the coping and core buildup. You say that you thought this was covered under your additional dental coverage. You say that you aren't sure how else the broken teeth would be repaired under the Plan. The Plan denied your request. The Plan says the services are not covered 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the coping and core buildup provided on February 13, 2020.