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

 
We decided that the Plan does not have to waive the coinsurance for End-Stage Renal Disease Services from 
January 1, 2022 through January 31, 2022. 
 
You asked the Plan to waive the coinsurance for End-Stage Renal Disease Services. You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says the cost share 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 a 20% 
coinsurance for End-Stage Renal Disease Services. The allowed amount of the services is $350.31, resulting in 
a coinsurance amount of $70.06. 
 
You have been asked to pay a 20% coinsurance for End-Stage Renal Disease Services. End-Stage Renal 
Disease Services falls within the Services to treat kidney disease 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 End-Stage Renal Disease Services from January 1, 2022 through January 31, 
2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan.
You asked the Plan to provide coverage for a PET scan. You say that at the time of the appeal a PET scan was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan says that Maximus did not apply the correct Medicare criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that a whole-body positron
emission tomography (PET) scan for the evaluation of prostate cancer is non-covered for initial treatment
strategy. Therefore, while a PET scan may have been beneficial for you, it was not covered for your condition
at the time of the appeal. Therefore, we decided that the Plan does not have to provide coverage for a Positron
Emission Tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 17, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this evaluation should not be 
denied. You also say that the initial provider should not have charged for an evaluation because she did not do 
any evaluation other than just looking at your tooth. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on October 5, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that you are unable to eat, and it is 
becoming an issue. You have been waiting since July 2020 for these dentures and you would like the denial 
reversed. The Plan denied your request. The Plan says you have exceeded the maximum allowed benefit for 
this service. 
 
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. The Plan covers a complete 
upper denture every five plan years.  
 
We looked at the file and Medicare rules. The records show that you had a complete upper denture provided to 
you on July 15, 2020, and the EOC confirms you are allowed a complete upper denture once every five plan 
years. Therefore, you have exhausted your maximum allowed benefit. Based on this information, we decided 
that the Plan's rules for coverage of complete upper denture have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on 
December 29, 2021. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you would like to know if the billing 
for this service can be changed to the 2022 plan year. The Plan denied your request. The Plan says the annual 
limit allowed by your dental plan has been paid for the 2021 benefit year. 
 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 Plan pays up to $1,250 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you 
are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit while processing this claim for the December 29, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
mandibular partial denture (D5214) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750 x2) 
provided on February 11, 2022. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that you are on a fixed income and 
cannot afford an additional bill for this large amount. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that you contacted the Plan on the 
date of service and were advised that these services were not covered under your policy. 
 
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 pay for the pontic 
(D6240) and two retainer crowns (D6750 x2) provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 17, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee was an inpatient on the date of service and this claim should be submitted to
the facility. Maximus overturned the Plans denial as insufficient information had been submitted to confirm the
enrollee was an inpatient on the date of service. The Plan requested a reopen and provided documentation to
show the enrollee was indeed in inpatient status when this testing was ordered, and payment would fall under
the facility claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that Medicare does
not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The
facility or hospital must furnish all necessary covered services to the beneficiary either directly or under
arrangements made with outside providers.
This testing was ordered during an inpatient stay. Payment for this service would have been included under the
facility claim. Payment to you for this service is the responsibility of the facility or hospital.
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March
17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an Extremity Brace on January 13, 2022.

You asked the Plan to waive the coinsurance for an Extremity Brace. You say that the brace is useless and you don't feel that you should pay for it. The Plan denied your request. The Plan says the cost share 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 a 20% coinsurance for Extremity Brace. The allowed amount of the Extremity Brace is $234.34, resulting in a coinsurance amount of $46.86.

You have been asked to pay a 20% coinsurance for Extremity Brace. Extremity Brace falls within the Durable medical equipment (DME) 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 an Extremity Brace on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
November 10, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you shouldn't have to 
pay for such a bad experience at a hospital. 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 when in-
network, a $250 copayment per visit, per provider, per day for surgery performed in an outpatient hospital 
setting.  
 
 
  You have been asked to pay $250 for outpatient surgery services. Outpatient surgery services fall within the 
Outpatient surgery, including services 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 copayment for outpatient surgery services 
provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on December 14, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. 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 Domiciliary services provided on December 14, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for the custom-fabricated oral device/appliance provided on April
18, 2021.
You asked the Plan to pay for this appliance. You say that this appliance should be covered by the Plan. The
Plan denied your request. The Plan says this appliance is not covered. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and showed documentation indicating this
claim denied because a referral is required for this service. This was coded as a medical procedure appliance
which requires referral and prior authorization both in and out of network. Theses services were provided out
of network. There is not referral on file from the primary care physician which is also required.
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.
The 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 the custom-fabricated oral device/appliance
provided on April 18, 2021, out of network.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a breast biopsy provided on November 22, 
2021. 
 
You asked the Plan to reduce the copayment for a breast biopsy. You say that this facility is separate from the 
hospital, and you should only be charged $250. 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 $300 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
The Plan confirmed the claim was billing through the hospital and it is not a separate facility. You have been 
asked to pay a $300 copayment for a breast biopsy. A breast biopsy falls within the Outpatient Surgery, Including Services 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 reduce the copayment for a breast biopsy provided on November 22, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from November 26, 2021, to December 1, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you should not be charged since the diagnosis was incorrect. 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 $298 per day for days 1-7 and $0 per day for days 8-90 for each inpatient admission.

The file shows that you were in the hospital from November 26, 2021, to December 1, 2021, but there is no copayment for the discharge date. Please note that the diagnosis for the inpatient stay does not affect the copayment amount. Therefore, you have been asked to pay $298 per day for the first 5 days of inpatient care. The total for your stay is $1,490 ($298 copayment x 5 days = $1,490). The inpatient care falls within the Inpatient Hospital 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 inpatient hospital care provided from November 26, 2021, to December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says while a portion of this claim was paid, the Medicare billing criteria were not met for
codes G0453, 95929 and 95938. Maximus partially overturned the Plans denial for insufficient information in
the case file. The Plan requested a reopen and provided the required claim information.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, at the time of
the appeal, codes G0453, 95929 and 95938 were not eligible for review. After additional records were
received, these codes were processed and paid on November 4, 2021. Therefore, while this claim could not be
paid at the time of submission, it has now been resolved and paid. Therefore, we decided that the Plan does not
have to pay for this claim as originally billed, which has now been shown to be resolved.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive or reduce the cost share for services provided on August 18, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share was correct. The
Plan denied your request. The Plan says this cost share was applied based on the Plan contract and the claim
submitted by your provider. Maximus partially overturned the Plans denial stating they needed to pay for code
29065. The Plan requested a reopen and stated that you are not being charged for that code and the cost share
charged was for the office visit, injection, and supplies, which was the same decision made by Maximus.
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 cost share for office visits, injections and items such as casting supplies.
The Plan has demonstrated that you are not being charged for code 29065 and 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 or reduce any of the cost share for services and
supplies provided on August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
November 15, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you were transferred to 
another hospital because they did not have the proper equipment to treatment you. 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 $315 
copayment per day for days 1-7 for an in-network inpatient hospital stay. The contract also says there is a $0 
copayment for days 8-90. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $945, which is a $315 copayment per day for a three-day inpatient hospital stay ($315 copayment x 3 
days + $945). There is no charge for the day of discharge. An inpatient hospital stay falls within the Inpatient 
Hospital 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 copayments for an inpatient hospital stay 
provided from November 15, 2021, to November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on February 10, 2022. 
 
You asked the Plan to pay for the crown. You say that you would like help paying for this service. The Plan 
denied your request. The Plan says this procedure is not a benefit under the dental 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 the crown 
(D2740) provided on February 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the bone density scan provided on December 2, 2021. 
 
You asked the Plan to pay for the bone density scan. You say that the radiologist is associated with a hospital 
that is in-network. You do not believe that you should be penalized due to their mistake in not requesting 
authorization. The Plan denied your request. The Plan says that a request to a noncontract provider was made 
for records, but no records were submitted. 
 
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. In this case, the Plan indicated that records were requested but not received, and 
for this reason, it cannot be determined that the services were medically necessary. However, it is not clear 
from the file whether the request was sent to an appropriate provider. The request for records was sent to a 
provider label on the submission form to Maximus as out-of-network; however, there is no mention that this 
provider is involved in the case which was billed by a radiologist. In addition, you indicate that this provider is 
affiliated with a network hospital and that they should know the authorization requirements. The Plan did not 
indicate where the services took place and whether the radiologist or the facility is in-network. Without 
confirmation of the network status, we cannot find in the Plan's favor. The denial of payment is not 
substantiated. Therefore, we decided that the Plan has to pay for the bone density scan provided on December 
2, 2021.  
 
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.