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

We decided that the Plan does not have to pay for home COVID-19 test purchased on January 18, 2022, and
January 27, 2022.
You asked the Plan to pay for this testing. You say that these tests should be covered by the Plan. The Plan
denied your request. The Plan says coverage for these tests did not being until February 1, 2022. Maximus
overturned the Plans denial. 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 state Plans can choose to cover home COVID-19 testing as a
supplemental benefit. The Plan contract states that coverage for home testing began on February 1, 2022. These
kits were purchased before that benefit began.
Therefore, we decided that the Plan does not have to pay for home COVID-19 test purchased on January 18,
2022, and January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation services provided on March 29, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation services. 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 it was determined these services can be received 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 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 telephone evaluation services provided on March 
29, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551.  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, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves (A4930) and tubing extension set (S1015) 
provided on September 17, 2021. 
 
You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says Medicare billing regulations have not been 
satisfied for these codes. 
 
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 looked at the file and Medicare rules. In this case, code A4930 has a Payment Status Indicator of N 
indicating that is packaged and no separate payment will be made. In addition, S1015 is not valid for Medicare 
purposed as it is a unique temporary code for private payor use. Based on this information, we decided that 
Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan 
does not have to pay for the sterile gloves (A4930) and tubing extension set (S1015) provided on September 
17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a periodic oral evaluation (D0120), 
prophylaxis (D1110), bitewing x-rays (D0274), and a panoramic x-ray (D0330) provided on April 19, 2022. 
 
You asked the Plan to waive the copayments for the dental services. You say that you were not aware of the 
changes this year and you thought preventive services were covered in full. 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 $15 
copayment per service during the visit for covered routine dental services when provided by an in-network provider. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $60, which is a $15 copayment for each dental service ($15 copayment x 4 services = $60). The dental 
services 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 waive the copayments 
for a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and a panoramic x-ray 
(D0330) provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) and implantable neurostimulator electrode (L8680) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because the enrollee's records show the enrollee has not had medical management.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee needs to complete a trial of physical therapy and other conservative therapy prior to a spinal cord stimulator trial. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) and implantable neurostimulator electrode (L8680) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extremity brace on March 24, 2022. 
 
You asked the Plan to waive the coinsurance for extremity brace. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost-sharing 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 a 20% 
coinsurance for Medicare-covered prosthetic devices or 20% coinsurance for other related medical supplies. 
Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited 
to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, 
artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain 
supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. The provider billed 
in the amount of $121.70 and the allowed amount is $99.41. The Plan paid $79.53. $99.41 - $79.53 = $19.88. 
Therefore, results in the total cost-sharing amount of $19.88. 
 
 
 You have been asked to pay a 20% coinsurance for extremity brace. Extremity brace falls within the Prosthetic 
devices and related 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 coinsurance for extremity 
brace on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for an eye procedure (00140) provided on June 
29, 2021. 
 
You asked the Plan to pay for anesthesia. You say that these services were medically necessary and were pre-
approved. The Plan denied your request. The Plan says they have agreed to pay for the anesthesia services 
billed as 00140-AA-QS for this date; however, the line billed only with procedure code 00140 is missing the 
modifiers necessary to process this claim line for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that for anesthesia services/claims, physicians must report the 
appropriate modifier to denote whether the service meets the requirements for payment at the personally 
performed rate, medically directed rate, or medically supervised rate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of anesthesia for an eye procedure 
(00140) provided on June 29, 2021 have been met. Specifically, this claim line was not billed with the 
necessary modifiers to denote whether the services meet the requirements for payment at the personally 
performed rate, medically directed rate, or medically supervised rate. Therefore, we decided that the Plan does 
not have to pay for anesthesia for an eye procedure (00140) provided on June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for an injection on February 15, 2022. 
 
You asked the Plan to waive the $250 copayment for an injection. You say that you should not be responsible 
for this copayment. The Plan denied your request. The Plan says you must pay a $250 copayment for 
Medicare-covered surgery at an outpatient hospital. 
 
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 $250 
copayment for Outpatient Surgery and Other Medical Services Provided At Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 You have been asked to pay a $250 copayment for an injection. An injection falls within the Outpatient 
Surgery and Other Medical Services Provided At 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 $250 copayment for an injection on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the full amount for the gingivectomy or gingivoplasty (D4211) provided 
on January 26, 2022, by the out of network provider. 
 
You asked the Plan to pay the full amount for the dental service. You say that there is no network requirement 
for dentists. You say that consequently the provider cannot be out of network. You also say that an additional 
$65 should be reimbursed to you. The Plan denied your request. The Plan says that the claim processed 
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 does not say in clear and accurate terms 
how much you should expect to pay for dental services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $65 
copayment for Dental Services. The Plan contract does not clearly say how much enrollees must pay for dental 
services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
Therefore, we decided that the Plan has to pay the full amount for the gingivectomy or gingivoplasty (D4211) 
provided on January 26, 2022, by the out of network provider.  
 
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 pay for gingival irrigation in all four quadrants (D4921) provided on 
January 26, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says gingival irrigation (D4921) is not covered by your routine 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. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation in all four quadrants (D4921) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foresee Home diagnostic testing. 
 
You asked the Plan to pre-approve Foresee Home testing. You say that this is medically necessary and covered 
by Medicare. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because studies have not proven this service is helpful for treatment of the enrollee's health problem. 
 
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 Foresee Home testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical value and effectiveness of this testing in the setting of the enrollee's 
condition has not been demonstrated in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Foresee Home testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Foresee Home diagnostic testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from December 27, 2021, to January 17, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you had to stay one extra day 
because you had no transportation. 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 for days 
1-20: a $0 copayment per day, per admission. Day 21-100: $160 copayment per day, per admission.  
 
 
  You have been asked to pay $160 for the SNF stay. The SNF stay falls within the Skilled Nursing Facility 
(SNF) 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 a skilled nursing facility 
(SNF) stay provided from December 27, 2021, to January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urinary surgery performed on March 10, 
2022. 
 
You asked the Plan to waive the copayment for urinary surgery. You say that you dont believe this was a 
surgery so it shouldn't be billed that way. The Plan denied your request. The Plan says the copayment applied 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 $150 
copayment for Medicare-covered outpatient hospital surgery services.  
 
You have been asked to pay $122.83 which is less than the standard $150 copayment for urinary surgery. 
Urinary surgery 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 urinary surgery performed on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not feel you should be responsible for this 
bill. You also say that the provider was in network. The Plan denied your request. The Plan says the claim 
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, the limited oral evaluation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for home health services provided on January 
4, 2022, to January 27, 2022. 
 
You asked the Plan to waive the deductible for home health services. You say that you weren't aware the 
deductible started over each year. The Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to Home Health Agency Care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Home 
Health Agency Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$500 deductible which applies to Home Health Agency Care. This cost sharing is a contractual obligation that 
had not been met at the time home health services was received on January 4, 2022, to January 27, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for home health services provided on 
January 4, 2022, to January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided from January 5, 2022, 
to February 19, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that the cost almost doubled, and you 
dont understand why. The Plan denied your request. The Plan says the coinsurance applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B covered drugs.  
 
 
 
 
 
 
 
 The enrollee has been asked to pay $566.72 which is 20% of the allowed amount for injections.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
January 5, 2022- 
January 11, 2022 
Injections $743.32 20% $86.24 
January 12, 2022- 
January 18, 2022 
Injections $743.32 20% $86.24 
January 19, 2022- 
January 22,2022 
Injections $390 20% $49.28 
January 23, 2022- 
January 29,2022 
Injections $689.68 20% $86.24 
January 30, 2022- 
February 5, 2022 
Injections $689.68 20% $86.24 
February 6, 2022- 
February 12, 2022 
Injections $689.68 20% $86.24 
February 13, 2022- 
February 19,2022 
Injections $689.68 20% $86.24 
Total:    $566.72 
 
 
Injections fall within the Medicare Part B Prescription Drugs 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 coinsurance for injections provided from January 5, 2022, to February 19, 2022.