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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on  
April 18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford this 
charge. 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). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency services provided in an emergency room setting.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 06, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $45 
copayment for specialists office visit. Covered services include consultation, diagnosis, and treatment by a 
specialist. The provider billed in the amount of $106 and the Plan discount is $62.54. $106 - $62.54 = $43.46. 
This is less than the copayment amount. Therefore, results in the total cost sharing amount of $43.46. 
 
You have been asked to pay a $43.46 copayment, which is less than the copayment for office visit. Office visits 
fall within the Physician/Practitioner services, including doctor's office visits 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 office visit on April 06, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit (90837) provided on February 9, 2022 
to February 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that the services should be covered as you 
disagree with the denial and were not aware of the providers network status. The Plan denied your request. The 
Plan says the services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
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 a psychotherapy visit (90837) provided on 
February 9, 2022 to February 23, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on May 25, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hospital services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 hospital services provided on May 25, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning (99497) provided on January 13, 
2022. 
 
You asked the Plan to pay for code 99497. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 99497 
 
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 99497 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, the submitted medical 
records do not include the documentation of a discussion between the provider and the enrollee, along with family member(s), or surrogate(s), regarding eventual end-of-life decisions and preferences on the billed date 
of service. Based on this information, we decided that Medicare rules for coverage of code 99497 have not 
been met. Therefore, we decided that the Plan does not have to pay for the advance care planning (99497) 
provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $175 copayment for outpatient hospital services "IV Therapy" provided on November 4, 2021.
You asked the Plan to waive this cost share. You say that you do not believe you received these services. The Plan denied your request. The Plan says this cost share was applied based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial for a lack of medical records to show these services were provided. The Plan requested a reopen and provided the required medical records.
The Plan is correct in this case. Based on the medical records provided, the following is stated, "On assessment the patient remains fluid overload. The patient was IV diuresed with Furosemide 80 mg IV push 1 dose." This confirms you were provided with IV therapy and the appropriate copayment 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 $175 copayment for outpatient hospital services. 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 $175 copayment for outpatient hospital services "IV Therapy" provided on November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance ($775.52) charged for air ambulance provided on November 28, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was applied based on the Plan contract agreement and the claim submitted by the provider. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the Medicare-allowed amount for the air ambulance services was $4,226.42. 20% of $4,226.42 is $845.28, which would normally be applied to this claim. However, when this claim was processed on January 4, 2022, there was only $775.52 remaining to meet your Maximum Out of Pocket (MOOP) for 2021. When the claim was paid, only $775.52 was applied to the coinsurance, which satisfied the 2021 MOOP. The 2021 MOOP satisfaction notice was subsequently issued to you on January 5, 2022. Also, while it is noted that the co-insurance for this claim was only listed on line 1, the co-insurance was applied for the entire claim allowed amount, not just the amount listed on line one. The claim required manual processing because the 2021 MOOP was satisfied with this claim.
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 20% coinsurance for air ambulance transport.
You have been asked to pay the correct amount based on your contract with the Plan which is $775.52. 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 20% coinsurance charged for air ambulance provided on November 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for specialist services provided on February 9, 2022.
You asked the Plan to waive this copayment. You say that you do not believe 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 agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language. The Plan demonstrated that these services were billed as pre-admission testing in preparation for surgery. The physician assistant who provided these services bills as a specialist. The was not a general physician or primary care physician visit.
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. Your contract with the Plan clearly says that you must pay $40 copayment for specialist office services. This was a visit in preparation for surgery. 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 $40 copayment charged for specialist services provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement battery provided on November 7, 2021. 
 
You asked the Plan to pay for the replacement battery. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the item rendered is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no separate allowance for replacement 
batteries (A4630) used with a TENS unit. 
 
We looked at the file and Medicare rules. Review of the file shows that the battery billed with the TENS unit is 
not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
replacement battery have not been met. Therefore, we decided that the Plan does not have to pay for the 
replacement battery provided on November 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the partial 
upper dentures (D5213) provided by an out-of-network provider on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that there were benefit 
limitations. The Plan denied your request. The Plan says your benefits for the requested items or services have 
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 Plan's 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 comprehensive oral evaluation was exhausted on date of service July 12, 2021, and 
the partial upper denture was exhausted on October 1, 2021. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) and the partial upper dentures (D5213) provided by an 
out-of-network provider on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) and a cone beam CT capture 
(D0364) provided by an out-of-network provider on April 6, 2022. 
 
You asked the Plan to pay for endodontic therapy and a cone beam CT capture. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says the enrollee has no out-of-network 
benefits. 
 
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.  
 
We looked the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage 
of endodontic therapy and a cone beam CT capture have not been met. Therefore, we decided that the Plan 
does not have to pay for endodontic therapy (D3330) and a cone beam CT capture (D0364) provided by an out-
of-network provider on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and 
efficacy when used as bone graft material. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right and left elbow supports. 
 
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 included in the already approved adjustable elbow supports. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the Plan has approved adjustable elbow supports. The requested right and left elbow 
supports serve the same purpose as these approved adjustable elbow supports. Therefore, we decided that the 
Plan does not have to pre-approve right and left elbow supports.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve a partial denture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that that the x-rays do not show any missing teeth in the enrollees lower 
jaw. 
 
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 a partial 
denture 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 a partial denture. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that a lower partial denture would allow for 
stabilizing the arches by providing an occlusion for tooth #2 and #15, and modestly helping with mastication as 
well. Given these issues, a lower partial denture would be considered necessary and reasonable. 
 
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 a partial denture have been met. Therefore, we decided that the Plan has to pre-
approve a mandibular partial denture (D5226).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature (L5845). 
 
You asked the Plan to pre-approve a prosthetic. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the requested prosthetic cannot be used for this 
prosthetic component and is unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code L5845 is not supported in the medical record. Specifically, although the manufacturer 
uses code L5845 for this knee, neither the manufacturer nor the vendor has the authority to assign this code to 
the requested knee. Based on this information, we decided that Medicare rules for coverage of a prosthetic have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-
shin system, stance flexion feature (L5845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown bridge (D6750) 
 
You asked the Plan to pre-approve the retainer crown bridge. You say that the services should be covered as 
you disagree with the denial, and they are medically necessary. The Plan denied your request. The Plan says the 
services denied correctly as you do not qualify for them. Bridges will only be covered if no other teeth 
are missing in the same arch other than 3rd molars. 
 
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. Therefore, we decided that the Plan does not have to pre-approve a 
retainer crown bridge (D6750).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical services (CPT code(s): 63052, 22480, 
20936 and 22830). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show that they have a medical condition that 
requires a fusion (surgery that involves jointing two areas of the spine together). The Plan states the records do 
not show that they had tried six weeks of therapy within the last six months. 
 
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 surgical services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a 6-week trial of physical therapy is needed. More conservative measures needed. 
 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical services (CPT code(s): 63052, 22480, 20936 and 22830).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says that additional therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the available records the enrollee appears to have 
improved with therapy to the point of being able to manage ambulation often without an assistive device, 
ascending and descending stairs and performing cleaning chores in their home. Further utilization of a home 
exercise program appears appropriate at this point. Repetitive exercise does not require the expertise of a 
professional skilled physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five physical therapy visits.