Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on September 8, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was 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 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.74 
Genvisc Drug $411.00 $205.50 
Total:  $289.08 
 
You have been asked to pay $289.08, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. the injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug 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 for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for out of network eye exam services provided on September 17,2021.
You asked the Plan to pay this bill. You say that these services should be covered by the Plan. The Plan denied
your request. The Plan says you did not have prior authorization for out of network care. Maximus overturned
the Plans denial stating the contract is not clear that supplemental vision services cannot be provided out of
network. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. 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. This was billed as a medical
vision exam.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided a medical vision exam. The Plan did not pre-approve out of network 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 out of network eye exam services provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, and the 
removal of plaque (D1110, D0150, D0210) provided on August 5, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral x-ray, and the removal of plaque. 
You say that the services should be covered as you disagree with the charges. The Plan denied your request. 
The Plan says the cost-sharing applied correctly. When services are provided out-of-network you may pay 
more. The dentist can bill you for additional costs if what they charge is more than the maximum payable 
benefit amount for preventive services covered by the plan. 
 
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, 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 a 
comprehensive oral evaluation, intraoral x-ray, and the removal of plaque (D1110, D0150, D0210) provided on 
August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that your health is deteriorating, and you 
need care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care facility. The health plan has approved ongoing care in the current acute care facility. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says the records received 
do not indicate that the enrollee had an emergent or urgent medical condition or was in need of specialized 
services that are not available in the 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 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 an office visit provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of teeth. 
 
You asked the Plan to pre-approve extraction of teeth. You say that your teeth are breaking from cancer 
treatment, and you need to get your teeth extracted. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
extraction of teeth.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem-focused oral evaluation (D0140) and periapical x-
rays (D0220 and D0230) provided on August 23, 2021. 
 
You asked the Plan to pay for the evaluation and x-rays. You say that the services should be covered because 
they are medically necessary. The Plan denied your request. The Plan says these services are not covered under 
your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Additionally, these services do not qualify for coverage under your 
medical benefits. Therefore, we decided that the Plan does not have to pay for a problem-focused oral evaluation (D0140) and 
periapical x-rays (D0220 and D0230) provided on August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed on September 2, 2021. 
 
You asked the Plan to waive the coinsurance for the injection with fluoroscopic guidance. You say that you 
were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was 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 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.74 
Genvisc Drug $411.00 $205.50 
Total:  $289.08 
 
You have been asked to pay $289.08, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug 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 for a genvisc joint injection with fluoroscopic guidance performed on September 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and pontic provided on January 10, 2022. 
 
You asked the Plan to pay for the crown and pontic. You say that you did not realize your dentist was not an in-
network provider. The Plan denied your request. The Plan says services are denied because services were 
rendered by a provider who is not participating with your plan. 
 
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, coverage only applies if you use a Plan 
provider. The records show you did not receive these services from a Plan provider. Therefore, we decided that 
the Plan does not have to pay for a crown (code D6752) and a pontic (code D6242) provided on January 10, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $100 copayment charged for outpatient services (echo
ultrasound) provided on November 9, 2021.
You asked the Plan to waive this copayment. You say that you do not think this copayment is correct. The Plan
denied your request. The Plan says this copayment was charged based on the services provided and the Plan
contract. Maximus overturned the Plans denial due to insufficient claim information in the case file. The Plan
requested a reopen and submitted the required claim information.
The Plan is correct in this case. 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 $100 copayment for each outpatient ultrasound. The Plan submitted the
documentation to show this service was provided and billed appropriately.
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 $100 copayment charged for outpatient services (echo ultrasound) provided on
November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (code D3330) and prefabricated post 
and core (code D2954) provided on January 5, 2022. 
 
You asked the Plan to pay for the endodontic therapy and post and core. You say that this service was approved 
but not paid for by the Plan. The Plan denied your request. The Plan says the service was approved based on 
the Plan's 2021 Evidence of Coverage (EOC), but the service was provided on January 5, 2022. Therefore, the 
Plan's 2022 EOC rules apply, and are not covered. 
 
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 for 2022. Therefore, we decided that the Plan does not have to pay for 
the endodontic therapy (code D3330) and prefabricated post and core (code D2954) provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for hip injections performed from January 24, 
2022, to February 21, 2022. 
 
You asked the Plan to waive the copayments for the injections. You say that you were not aware of the 
copayments at the times of service. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 
copayment per visit for surgery or services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $390 copayment per visit for the injections. The total for all three visits is $1,170 
($390 copayment x 3 visits = $1,170). The injections fall within the Outpatient Surgery, Including Service 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 hip injections performed from January 24, 2022, to February 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair (PWC) repairs to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON PWC repairs. You say that this is medically necessary. The Plan 
denied your request. The Plan says the repairs can be provided by several in-network PWC suppliers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
power wheelchair (PWC) repairs to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you request a 
gap authorization as there is no in-network provider that carries the pump that the physician is requesting in the 
enrollee's geographical area. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
as the records show the enrollee only has swelling in their legs and do not have swelling in the trunk or belly. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. A PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the records show that the enrollee only has lymphedema 
in their extremities due to chronic venous insufficiency and none in the trunk or abdomen. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 28, 2021. 
 
You asked the Plan to pay for physician's services. You say that this is not a Hospice related claim. The Plan 
denied your request. The Plan says hospice was the primary payer at the time of service and traditional 
Medicare would be responsible for date of service October 28, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on October 27, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), sphere, single vision, plano to plus or 
minus 4.00, per lens (V2100), lens, polycarbonate or equal, any index, per lens (V2784), and anti-reflective 
coating, per lens (V2750) provided September 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine eyewear. You say that eyewear was covered from this provider last 
year. The Plan denied your request. The Plan says this eyewear is not covered because it was purchased OON. 
 
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 covers these services when purchased from a network optical provider. 
 
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that 
the Plan does not have to pay for the frames (V2020), sphere, single vision, plano to plus or minus 4.00, per 
lens (V2100), lens, polycarbonate or equal, any index, per lens (V2784), and anti-reflective coating, per lens 
(V2750) provided September 30, 2021, by an out-of-network (OON) provider.  
 
Your complaint about potential differences in coverage or provider status from year to year is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 8, 2021. 
 
You asked the Plan to pay for physician's services. You say that the member was not in Hospice on this date of 
service. The Plan denied your request. The Plan says Hospice was the primary payer at the time of service and 
therefore traditional Medicare would be responsible for dates of service November 8, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on November 1, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his 
physician assistant for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is 
considered experimental and investigational. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).