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

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, preventive procedure, 
and resin-based composite provided on July 9, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, preventive procedure, and resin-based 
composite. You say that you did not realize you had gone to an OON provider. You also say that you have full 
coverage for one bitewing x-ray every year, and thought the x-rays would be covered independently. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
your plan does not allow for OON services. 
 
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 periodic 
oral evaluation, bitewings, preventive procedure, and resin-based composite provided on July 9, 2020 by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care visit of 30-74 minutes (99291) provided 
December 18, 2019. 
 
You asked the Plan to pay for the critical care visit. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the records do not support the service billed. 
 
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 evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes. 
 
We find that CPT code 99291 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. The records show that the plan had made 
several attempts to the provider to obtain the needed information without success. Based on this information, 
we decided that Medicare rules for coverage of the critical care visit have not been met. Therefore, we decided 
that the Plan does not have to pay for critical care visit of 30-74 minutes (99291) provided December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET) 
scan rendered on July 14, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the procedure was stopped. 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 $150 
copayment for each advanced imaging service (e.g. PET scans).  
 
Review of the file shows that you received a PET scan on July 14, 2020. The records support that the procedure 
was completed. You have been asked to pay a $150 copayment for these services. These services fall within the 
advanced imaging service (e.g. PET scans) 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 positron emission tomography (PET) scan rendered on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies identified 
with codes A9276 and A9277. 
 
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that codes A9276 and A9277 describe the supplies 
used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continuous glucose monitor (CGM) supplies identified with codes A9276 and A9277.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ultrasound examinations provided on May 
12, 2020. 
 
You asked the Plan to waive the copayments for ultrasound exams. You say that you were never told of any 
copayments associated with these tests, and if you were made aware of the cost-sharing prior to service you 
would more than likely have refused them. The Plan denied your request. The Plan says the copayment 
amounts you are being charged are 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 $160 
copayment for each ultrasound exam. There were 4 ultrasound exams, so a separate copayment applies to each 
exam. For some of the exams, you have been asked to pay the allowed amount of the service, if it is less than 
the $160 copayment for radiological diagnostic services. 

Your total cost-sharing obligation is therefore $437.85. 
 
You have been asked to pay $160 copayment or less for each ultrasound exam. Ultrasound exams 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 ultrasound examinations provided on May 12, 2020.  
 
Your complaint regarding not being told about the cost-sharing for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens upgrades you received on June 23, 2020. 
 
You asked the Plan to pay for the lens upgrades. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover lens options/upgrades for eyewear. 
 
We looked at the file and the Plan's rules. The requested lens upgrades are not covered under your plan. Based 
on this information, we decided that the Plan's rules for coverage of the lens upgrades have not been met. 
Therefore, we decided that the Plan does not have to pay for the lens upgrades you received on June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 63081 and 22854 are not supported. 
 
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 63081 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single 
segment. The definition of code 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic 
cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, 
to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with 
interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure). 
 
We find that CPT codes 63081 and 22854 are not supported in the medical record. Specifically, there is no 
documentation of a partial or complete vertebral corpectomy to support code 63081. There is no documentation 
of insertion of an intervertebral biomechanical device to support code 22854. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services rendered on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is necessary. The Plan denied your request. 
The Plan states Medicare coverage criteria are not met.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that Medicare coverage 
criteria are not met. Our physician reviewer found the documentation does not support that this drug is 
expected to be safe and effective for the enrollee in this case. We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 13, 2020. 
 
You asked the Plan to pay for the diagnostic radiology 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 
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 diagnostic radiology services provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214, 99397, G0101, Q0091) provided on 
March 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that there was miscommunication about 
authorization at the time of service. The Plan denied your request. The Plan says this was 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 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 office visit (99214, 99397, G0101, Q0091) 
provided on March 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on May 15, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 
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 nurse practitioner services provided on May 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 20, 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 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 test 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 rendered on February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the hyperbaric oxygen therapy provided from 
April 13, 2020, to May 7, 2020. 
 
You asked the Plan to waive the copays for the services provided. You say that you were never informed of the 
full cost, or your required portion of payment for the treatments. The Plan denied your request. The Plan says the 
cost shares are a contractual obligation that cannot be waived. 
 
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 $395 
copay for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
The file shows that you were charged a $395 copay for 15 hyperbaric oxygen treatments provided from April 
13, 2020, to May 4, 2020. You were charged a $175 copay for the treatment provided on May 7, 2020, due to 
meeting your out-of-pocket expenses.  
 
The services you received fall within the outpatient surgery and other medical services provided at hospital 
outpatient facilities 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 copays for the hyperbaric oxygen 
therapy provided from April 13, 2020, to May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you 
do not have access to the member's demographics prior to the date of service. The Plan denied your request. 
The Plan says utilization of network providers is required when possible and available. 
 
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 20, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you would like 
reconsideration because the member was just discharged from the hospital and has a pacemaker. The Plan 
denied your request. The Plan says the record does not show that the member is on home dialysis. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve the automatic blood pressure monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epoetin alfa injections rendered on March 3, 2020 to 
March 31, 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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the required route of administration modifiers for 
dialysis services are JA, JB and JE.  
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required JA, 
JB, or JE modifiers. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the epoetin alfa injections 
rendered on March 3, 2020 to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network benefit exception to an out-of-network 
provider. 
 
You asked the Plan to pre-approve an in-network benefit exception. You say that the requested HoLEP 
procedure is medically necessary and the Plan should allow a one-time in-network benefit exception for the 
out-of-network provider. The Plan denied your request. The Plan says the requested Holmium laser enucleation 
of the prostate (HoLEP) is not medically superior over the green light laser treatment of the prostate. HoLEP is 
not offered in-network, while green light laser treatment is. 
 
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 an in-network benefit exception. Our 
reviewer says that the requested in-network exception is not medically necessary. Our physician reviewer 
found the 2020 AUA Guidelines for the surgical management of BPH do not state that HoLEP is preferred over 
greenlight laser in larger prostate glands. These guidelines state that the choice of which of these procedures to 
utilize should be based upon the surgeon?s expertise. The plan's denial is medically justified on the basis that it 
is offering adequate care to meet the enrollee's medical needs through referral to an in-network provider with 
Green light laser treatment. The health plan has shown that they have in-network providers who meet the 
Standards of Care required for treatment of the enrollee's condition. There is nothing  unique about the 
enrollee's condition that would make it medically necessary for him to see the requested out-of-network 
provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an in-network benefit exception have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an in-network benefit exception to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided 
June 29, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you want the plan to remove this 
$15 copay from this claim as this appointment was supposed to be an annual wellness exam. The Plan denied 
your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence 
of Coverage. 
 
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 $15 
copayment for each PCP visit.  
 
You have been asked to pay $15 copayment for the office visit. The office visit falls within the outpatient 
hospital 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 the outpatient office 
visit (99214) provided June 29, 2020.