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

 
We decided that the Plan does not have to pay for group psychotherapy provided on November 30, 2021, to 
December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for group psychotherapy. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 group psychotherapy provided on November 30, 
2021, to December 3, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system and a vacuum assisted socket 
system (VASS) (CPT code(s): L5781 and L5910). 
 
You asked the Plan to pre-approve the items. You say that your current prosthetic does not fit, and you are 
unable to do what you use to do. The Plan denied your request. The Plan says replacement alignable system 
exceeds member's need and is reasonable and necessary for the approved replacement socket. The Plan states 
experimental and investigational items are not covered by Medicare: Vacuum Assisted Socket System (VASS) 
cannot be approved. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you had authorization of a new prosthesis at the K3 functional level. There is no indication 
from the medical documentation that the previous alignable system cannot be used with the new prosthesis. Additionally, the VASS is considered investigational. The requested device has not been shown to be superior 
to other standard treatments for the medical condition. The requested components are 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an alignable system and a vacuum assisted socket system (VASS) (CPT code(s): L5781 and 
L5910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair headlight repairs. 
 
You asked the Plan to pre-approve 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 state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested services are repairs to headlights. These services are for use outside of the home. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair headlight repairs.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on January 31, 2022. 
 
You asked the Plan to pay for genetic testing. You say that Medicare has determined this testing to be 
reasonable and necessary for the management of the enrollee's condition. The Plan denied your request. The 
Plan says that the denial of payment for this testing is correct, because there is no evidence to support the 
ordering provider was treating the enrollee. 
 
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 follows these rules. 
 
The enrollee was referred for genetic testing by a contract provider. The file does not show that the plan 
provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on 
January 31, 2022.  
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy on tooth #7 (D3310), a crown on 
tooth #7 (D2750), and a prefabricated post/core on tooth #7 (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary due to the maintenance of 
the tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the Plan provides coverage for 
the least costly treatment alternative. In this instance tooth #7, if not restorable with a simple restoration, then 
the tooth could be removed and replaced with a removable partial denture. This partial denture could also replace other missing teeth in the same arch. Although endodontic treatment and a crown is possible, the least 
expensive alternative would be the removable partial denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endodontic therapy on tooth #7 (D3310), a crown on tooth #7 (D2750), and a 
prefabricated post/core on tooth #7 (D2954).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 additional units of an antibody stain procedure (88341) 
provided on September 14, 2021. 
 
You asked the Plan to pay for additional units of an antibody stain procedure. You say that you have provided 
medical records to support the services at issue. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that an MUE for a HCPCS/CPT code is the 
maximum number of units of service under most circumstances allowable by the same provider for the same 
enrollee on the same date of service. 
 
We looked at the file and Medicare rules. In this case, 13 units of the service at issue are supported and have 
been approved by the Plan. Any further units are not supported due to code 88341 having an MUE of 13. Based 
on this information, we decided that Medicare rules for coverage of additional units of an antibody stain 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for 3 additional units of 
an antibody stain procedure (88341) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 7, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
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 subsequent nursing facility care provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and the 
intraoral complete series of radiographic images (D0210) provided on April 21, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that your benefit for the services provided in this case has been exhausted. Specifically, the Plan contract 
states that a comprehensive oral exam is covered once every thirty six months. You previously received this 
service on March 12, 2021, which was paid for by the Plan.  Additionally, the Plan contract states that an intraoral complete series of radiographic images is covered once 
every sixty months. You previously received this service on March 12, 2021, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for these services. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral examination (D0150) and the intraoral complete series of 
radiographic images (D0210) provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided from April 15, 
2022, to June 15, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for physician/practitioner services.  
 
The enrollee has been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. 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 a specialist visit provided from April 15, 2022, to June 15, 2022.  
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for the PT services provided from December 7, 
2021, to December 30, 2021.  
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded the 2021 Evidence of Coverage (EOC). 
Without this contract information, we are unable to verify the cost share amounts applied to any services 
rendered in 2021. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the 
Plans denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan has to 
waive the copayments for the PT services provided from December 7, 2021, to December 30, 2021.  
 
We also decided that the Plan does not have to waive the copayments for the PT services provided from 
January 3, 2022, to February 1, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physical therapy services.  
 
You have been asked to pay a $40 copayment for the PT services provided from January 3, 2022, to February 
1, 2022. The PT services fall within the Outpatient Rehabilitation Services benefit category. This means you 
have been asked to pay the correct amount based on your contract with the Plan. This 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 the PT services provided from January 3, 2022, to February 1, 2022. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayments for ferumoxytol infusions 
provided from February 10, 2022, to February 17, 2022. 
 
You asked the Plan to waive the coinsurance and copayments for the infusions. You say that you cannot afford 
the cost of the infusions. The Plan denied your request. The Plan says the correct coinsurance and copayments 
were 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 $350 
copayment for surgery or services provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 Service/Drug Allowed Amount Copayment/Coinsurance Actual Charges 
Infusion  February 10, 2022 - $350.00 $190.97 
Ferumoxytol  February 10, 2022 $557.43 $111.49 $111.49 
Infusion  February 17, 2022 - $350.00 $190.97 
Ferumoxytol  February 17, 2022 $557.43 $111.49 $111.49 
Total:   $604.92 
 
You have been asked to pay a total of $604.92 for the infusions. The infusion administration falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. The ferumoxytol falls within the Medicare Part B Prescription Drugs 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 and copayments for ferumoxytol infusions 
provided from February 10, 2022, to February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endodontic therapy (D3330) provided on February 15, 
2022, core build up (D2950) provided on February 27, 2022, and a crown (D2740) provided on March 18, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the amount paid for 
these dental services. 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 50% 
coinsurance for out-of-network covered supplemental comprehensive dental services.  
 
The record shows these services were approved, and you have a cost sharing amount. You have been asked to 
pay $275, which 50% coinsurance of the allowed amount for endodontic therapy on February 15, 2022 ($550 
allowed amount x 50% coinsurance = $275). You have also been asked to pay $37.50, which 50% coinsurance 
of the allowed amount for core build up on February 27, 2022 ($75 allowed amount x 50% coinsurance = 
$37.50). You have also been asked to pay $255.75, which 50% coinsurance of the allowed amount for a crown 
on March 18, 2022 ($511.50 allowed amount x 50% coinsurance = $255.75).  
 
Endodontic therapy, core build up, and a crown fall within the Dental 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 pay more for endodontic therapy (D3330) provided on February 15, 2022, core build up 
(D2950) provided on February 27, 2022, and a crown (D2740) provided on March 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0999) provided September 29, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance benefit is a transportation benefit. Items and services which include but are not limited to 
oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for 
ambulance services. This service is not separately payable. Therefore, we decided that the Plan does not have 
to pay for ambulance services (A0999) provided September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete series (D0210) provided on April 11, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 15, 2020. 
Therefore, we decided that the Plan does not have to pay for an intraoral complete series (D0210) provided on 
April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 LTACH services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.