Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on June 2, 2020. 
 
You asked the Plan to pay for the full mouth debridement. You say that you should be covered for a dangling 
piece of tooth. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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, full mouth debridement to enable a 
comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) is a covered benefit, and you are 
responsible for a 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the full mouth 
debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided 
on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a lumbar-sacral orthosis provided on April 13, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the denial of payment for this item is correct, because the 
records submitted do not indicate anything regarding an order or any type of need for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that a written order prior to delivery is required for a 
lumbar-sacral orthosis. The written order prior to delivery must contain all of the data elements described 
above. 
 
We looked at the file and Medicare rules. You submitted a detailed written order which included the 
beneficiary's name, order date, a general description of the requested item and the requested item code, the 
quantity to be dispensed, the ordering provider's name and National Provider Identifier (NPI), and a valid 
signature from the ordering provider. This order was submitted to you on April 10, 2020, while you furnished 
the lumbar-sacral orthosis on April 13, 2020, therefore this order is considered to be a written order prior to 
delivery (WOPD). Therefore, this order is sufficient to justify coverage of the lumbar-sacral orthosis billed on 
this claim. The Plan denied payment merely on the basis that the documentation submitted does not indicate an 
order for this item. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral 
orthosis have been met. Therefore, we decided that the Plan has to pay for a lumbar-sacral orthosis provided on 
April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291x4) provided October 1, 2019 
to October 7, 2019. 
 
You asked the Plan to pay for critical care. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says there is no documentation of critical care 
time spent to corroborate the services to confirm Medicare coverage has been met. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30?74 minutes. 
 
We find that CPT code 99291x4 is not supported in the medical record. Specifically, the documentation 
submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not include the time spent providing this service. Based on this information, we decided 
that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does 
not have to pay for critical care, first hour (99291x4) provided October 1, 2019 to October 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were provided by a non-contracted provider. The Plan states the 
services were not for an urgent or emergent reason and were available to be provided in-network. 
 
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 February 19, 
2020 by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on 
January 20, 2020. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are on a fixed income and do not 
feel that you should have to pay more than the specialist visit copayment. The Plan denied your request. The 
Plan says the copayment amount you are being charged is correct. 
 
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 $110 
copayment for in-network ultrasound exam.  
 
You have been asked to pay the allowed amount of $77.42, which is less than the $110 copayment for 
ultrasound. Ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound examination 
provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5257) provided on April 30, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because the 
provider fraudulently billed the claim in the amount of $3,465.00. The Plan denied your request. The Plan says 
the service is a covered benefit, but you have exceeded the limits set in the subscriber agreement. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to a 
$1,000 for hearing aids every 3 years.  
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Specifically, the record indicates that the Plan paid 
$1,000 towards the hearing aids. This is the maximum allowance for this benefit. Therefore, we decided that 
the Plan does not have to pay for hearing aids (V5257) provided on April 30, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 
16, 2019. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the attending provider told 
you that this would not be an emergency room visit. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $90 
copayment for emergency room visit.  
 
You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
visit provided on July 16, 2019.  
 
Your complaint regarding receiving inaccurate information about the place of service for your visit 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 28, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 a domiciliary, rest home visit provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on October 10, 2019. 
 
You asked the Plan to pay for the services. You say that you charge a lot less than other labs to perform this 
test. The Plan denied your request. The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. 
Guardant-360 and NEXT-Generation) requires use of CPT 81479 (for the entire multi-test panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on October 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastric band adjustment (S2083) provided on April 21, 
2020. 
 
You asked the Plan to pay for the gastric band adjustment. You say that you would like reconsideration because 
the provider told you that this service would be covered. The Plan denied your request. The Plan says this is a 
non-covered benefit. 
 
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 S2083 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S2083 has a status indicator of I. This means that CPT code S2083 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the gastric band adjustment have not 
been met. Therefore, we decided that the Plan does not have to pay for the gastric band adjustment (S2083) 
provided on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service 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 physician's services provided on June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from January 21, 2020 to 
January 23, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from January 21, 2020 to January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound rendered on May 13, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial 
hardship. The Plan denied your request. The Plan says the copayment was 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 $100 
copayment for each Medicare-covered radiological diagnostic service.  
 
Review of the file shows that you received a breast ultrasound on May 13, 2020. You have been asked to pay a 
$100 copayment for these services. These services fall within the Medicare-covered radiological diagnostic 
service 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 breast ultrasound rendered on 
May 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiological diagnostic services provided 
by a participating provider on March 10, 2020. 
 
You asked the Plan to waive the copayment for a radiological diagnostic services. You say that this should be a 
$30 copayment. 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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $93.53 which is less than your copayment amount of $160 for a radiological 
diagnostic services. A radiological diagnostic services falls within the outpatient diagnostic tests/radiological 
diagnostic services 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 radiological 
diagnostic services provided by a participating provider on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on November 6, 
2019. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 a hospital outpatient clinic visit provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a renal biopsy (50200) provided 
on July 31, 2019. 
 
You asked the Plan to pay for surgical assistant services on a renal biopsy. You say that surgical assistant 
services were medically necessary. The Plan denied your request. The Plan says surgical assistant services are 
not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
50200. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for surgical assistant services on a renal biopsy 
have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a 
renal biopsy (50200) provided on July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 8, 2019. 
 
You asked the Plan to pay for lab test. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an 
office setting, therefore the Place of Service (POS) code 81 ? indicating an independent laboratory setting ? is 
not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab 
test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided 
on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a Dexcom G6 continuous glucose monitor with supplies provided on 
February 26, 2020. 
 
You asked the Plan to pay for continuous glucose monitor. You say that your treating physician ordered these 
items for you. The Plan denied your request. The Plan says that the denial of payment for these items is correct, 
because you do not meet the criteria for a continuous glucose monitor. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether your treating physician who ordered these 
items is in-network or out-of-network with the Plan. The documentation submitted does not include prior 
notice from the Plan that these items would not be covered. You say that you were told these was an approval 
for these items. Without this information, we cannot determine whether the order made by your treating 
physician constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment 
and hold you responsible for the denied amount is correct or justified according to Medicare rules. Therefore, 
we decided that the Plan has to pay for a Dexcom G6 continuous glucose monitor with supplies provided on 
February 26, 2020.  
 
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.