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

 
We decided that the Plan does not have to pay for physician services provided on June 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on June 29, 2020 by 
an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aquatic therapy provided on October 21, 2019. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved so 10 visits were 
provided. You say that the claims should be processed for payment. The Plan denied your request. The Plan 
says the techniques used could have been applied using land based physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
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 aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there was no documentation in the records that land based physical 
therapy would have been inappropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from May 12, 2020, to May 23, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you shouldn't have 
to pay a second copayment for inpatient hospitalization because the patient was transferred from an out-of-
network facility to an in-network facility. The Plan denied your request. The Plan says this copayment was 
charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $335 copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for inpatient 
hospital care.  
 
The enrollee has been asked to pay a $335 copayment per day for days 1-5 for the inpatient hospital services. 
The Evidence of Coverage explicitly states that for inpatient care, the cost sharing begins on day one each time 
the patient is admitted or transferred. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
inpatient hospital services provided from May 12, 2020, to May 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for chiropractic treatment providedfrom January 6, 2020, through June 9, 2020.You asked the Plan to reimburse you for the chiropractic treatment. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 reimburse you 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 chiropractic treatment.We found no exception that would require the Plan to reimburse you forthese services. Therefore, we decided that the Plan does not have to reimburse you for chiropractic treatment providedfrom January 6, 2020, through June 9, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
May 6, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you left the ER before you saw the 
doctor, so you shouldn't have to pay the copayment. The Plan denied your request. The Plan says you were 
charged this copayment 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 $120 
copayment for emergency room services.  
 
You have been asked to pay a $120 copayment for the ER visit. Records show that during your ER visit you 
were triaged and had your blood pressure checked, so you did receive services from the ER.  This copayment 
applies regardless of the extent of ER services you receive. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the emergency room (ER) visit you had on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on April 27, 2020, through April 
28, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a status indicator C inpatient procedure code 
C9606 was billed on the outpatient claim. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the OPPS for services 
that CMS designates to be inpatient-only services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, this outpatient claim has been billed and an 
inpatient only code, C9606. This inpatient only code does not meet criteria for exception. Therefore, we 
decided that the Plan does not have to pay for outpatient services provided on April 27, 2020, through April 28, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on March 25, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were under the impression that the services 
would be covered. The Plan denied your request. The Plan says there is a $2,000 allowance for covered dental 
services. The Plan says the allowance has been exhausted. 
 
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 $2,000 allowance has been 
exhausted. 
Date of Service Plan Paid Your Responsibility 
1/14/2020 $1,190  
2/12/2020 $130  
2/19/2020 $179  
3/4/2020 $322  
3/6/2020 $179  
3/25/2020 $0 $1,267 
TOTAL: $2,000  
 
Additionally, the Evidence of Coverage clearly states that any amount over the allowance is your 
responsibility. Therefore, we decided that the Plan does not have to pay for the crown provided on March 25, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on April 21, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not support that these laboratory services were performed with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided. 
 
You asked the Plan to pay for the laboratory 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 payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation submitted did not support that these laboratory tests were performed 
with blood sampling. Blood specimen collection is by venipuncture, however, the lab requisition states a urine 
specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 
provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on August 20, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that your dental plan allows limited teeth 
cleaning, an exam and x-rays. You say that it's only fair to be billed the amount above a regular cleaning 
procedure. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided from May 26, 2020, to August 
13, 2020. 
 
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control 
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says the billed supply code cannot be verified. 
 
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 or proof of delivery supporting medical necessity for the  
supplies provided in this case. The Physician order is incomplete and written after the claim date, and the 
Delivery Ticket did not include the carriers tracking number. 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 the diabetic supplies provided from May 26, 2020, to August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on January 8, 2020. 
 
You asked the Plan to pay for emergency room services. You say that the charges are not related to hospice. 
You say that the claim should be processed for payment. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency room services provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on 
October 30, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition or medical records (signed by 
the ordering physician). Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
80307 and G0483 provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 13, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on March 13, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the root canal (D3330) and the intraoral x-ray 
(D0220) provided on July 1, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that you had no option but to move 
forward with the recommendations and findings and complete the work in progress. You say that you needed 
the services. You say that you have run through your dental allowance. You also say that this is an ongoing 
repair that will go through next year. The Plan denied your request. The Plan says there is an allowance of 
$2,000 per year. The Plan says that the allowance has been used up. The Plan also says that you are responsible 
for the remaining amount. 
 
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 allowance of $2,000 has been 
exhausted.  
Date of Service Plan Paid 
1/30/2020 $163 
2/3/2020 $973 
5/28/2020 $96 
7/1/2020 $1,081 
TOTAL: $2,313 
 
Therefore, we decided that the Plan does not have to pay the full amount for the root canal (D3330) and the 
intraoral x-ray (D0220) provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 21, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. The Plan states the code and modifier required for 
billing this service were not on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, based on the Medicare guidelines as 
states above, the claim submitted cannot be paid as billed. Therefore, we decided that the Plan does not have to 
pay for lab services provided to the enrollee on June 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP vaccine provided on January 17, 2020. 
 
You asked the Plan to pay for the TDAP vaccine under Medicare Part B. You say that the Plan should cover 
this vaccine. The Plan denied your request. The Plan says the TDAP vaccine is not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine 
under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or 
directly exposed to any illness related to the TDAP vaccine under Medicare Part B. Therefore, we decided that 
the Plan does not have to pay for a TDAP vaccine provided on January 17, 2020.  
 
Benefits for the TDAP 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair accessory, medial thigh support, prefabricated, 
including fixed mounting hardware, each, provided on March 19, 2020. 
 
You asked the Plan to pay for the wheelchair accessory, medial thigh support, prefabricated, including fixed 
mounting hardware, each. The Plan denied your request. The Plan says the Plan requires utilization of network 
providers when possible and available, and requires authorization for certain services. No medical necessity for 
an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for wheelchair accessory, medial thigh support, prefabricated, including 
fixed mounting hardware, each, provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on June 23, 2020. 
 
You asked the Plan to pay for annual wellness visit. You say that this was a wellness check and you were told 
there would not be a charge for this service. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because you already received an annual wellness visit on February 6, 2020; therefore, 
the benefit for this service was exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is only covered once per 
12 months.  
 
We looked at the file and Medicare rules. You received a previous annual wellness visit on February 6, 2020; 
therefore, 12 months had not passed before this visit was performed. Based on this information, we decided 
that Medicare rules for coverage of annual wellness visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an annual wellness visit provided on June 23, 2020.  
 
Your complaint regarding receiving inaccurate information from the provider about the coverage for this 
service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address 
grievances. Please contact the Plan for more information about your grievance.