Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient rehabilitation service 
provided on April 22, 2022, to June 07, 2022. 
 
You asked the Plan to waive the copayment for each outpatient rehabilitation service. You say that you were 
not aware of the cost for the PT services received and are not able to afford the copayments. The Plan denied 
your request. The Plan says this cost sharing was charged 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 a $35 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $35 copayment for each outpatient rehabilitation service. This item/service falls 
within the outpatient rehabilitation service 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 each outpatient rehabilitation service provided on April 22, 2022, to June 07, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 81455 and G0452 provided on May 14, 2022. 
 
You asked the Plan to pay for procedure codes 81455 and G0452. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make 
a determination within the allotted time frame. 
 
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 has not provided enough evidence to support the denial of 
payment for procedure codes 81455 and G0452 based on Medicare criteria. Therefore, we decided that the Plan 
has to pay for procedure codes 81455 and G0452 provided on May 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 94761 provided on August 29, 
2022. 
 You asked the Plan to pay for procedure codes 93005 and 94761. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 93005 is a packaged service due to being billed on the same claim as code 99285, 
which has a status indicator of V. We also find that procedure code 94761 has a status indicator of T on the 
Physician Fee Schedule. There was another payable service billed on the same date by the same provider. This 
means that procedure code 94761 is not separately payable. Therefore, we decided that the Plan does not have 
to pay for procedure codes 93005 and 94761 provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214) provided on October 12, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that you saw two doctors on the 
same day. You say that one was a cardiologist and the other a primary care physician. You also say that this bill 
should be paid. The Plan denied your request. The Plan says that the service at issue in this case was previously 
paid to another provider for the same date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support the Plan's denial. The provided 
documentation does not show that the two providers are in the same group. There was also nothing provided to 
indicate that the two providers are the same. Therefore, we decided that the Plan has to pay for the office visit 
(99214) provided on October 12, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more therapy. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for complete denture - maxillary (D5110) and 
complete denture - mandibular (D5120) provided on December 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you received a letter from your insurance stating the 
dentures would be covered in full, you were not expecting to have an out-of-pocket expense. The Plan denied 
your request. The Plan says they will not pay over the $1,000 annual maximum allowed. 
 
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. This benefit includes complete 
denture  maxillary and complete denture  mandibular  limited to 1 upper complete and/or 1 lower complete 
denture every 5 calendar years, including routine post-delivery care. The contract also says that there is an 
annual maximum of $1,000. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110 and D5120 are 
covered under this benefit but only up to the annual maximum of $1,000. Therefore, we decided that the Plan 
does not have to pay the full amount for complete denture - maxillary (D5110) and complete denture - 
mandibular (D5120) provided on December 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the mammogram and ultrasound services 
provided on July 5, 2022. 
 
You asked the Plan to waive the cost share for the mammogram and ultrasound. You say that you should not be 
charged any cost share since you are part of the Qualified Medicare Beneficiary program (QMB). The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $1,000 deductible which applies to out-of-network mammograms and 
ultrasounds. The Plan contract also says there is 40% coinsurance after your deductible is met for each 
Medicare-covered diagnostic radiology service, including ultrasounds. 
 You have been asked to pay $141.60 towards your deductible for the providers services for the mammogram 
and ultrasound. These items or services you asked the Plan to waive the cost share for fall within the outpatient 
diagnostic tests and therapeutic services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to out-of-network diagnostic services. 
This cost sharing is a contractual obligation that has not yet been met at the time the mammogram and 
ultrasound was performed on July 5, 2022. 
 
You have also been asked to pay $112.57 from the facility, which is 40% coinsurance of the allowed amount 
for the mammogram and ultrasound services ($52.73 coinsurance + $11.06 coinsurance + $48.78 coinsurance = 
$112.57). 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 cost share for the mammogram and ultrasound services 
provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K-3 level Flex-Walk foot (L5981) with multi-axial 
ankle with swing phase active dorsiflexion feature (L5968). 
 
You asked the Plan to pre-approve a K-3 level Flex-Walk foot with multi-axial ankle with swing phase active 
dorsiflexion feature. You say that the items are medically necessary. The Plan denied your request. The Plan 
says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 K-3 level Flex-Walk foot with multi-
axial ankle with swing phase active dorsiflexion feature. Our reviewer says that the member does not need 
these items. Our physician reviewer found the documentation doesn't support that the member is able to 
ambulate at a K3 functional level therefore the requested K3 level foot is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K-3 level Flex-Walk foot with multi-axial ankle with swing phase active 
dorsiflexion feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a K-3 
level Flex-Walk foot (L5981) with multi-axial ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services and a specialist office visit 
provided on October 5, 2022. 
 
You asked the Plan to waive the copayment for x-ray services and a specialist office visit. You say that you 
disagree with the copayments. The Plan denied your request. The Plan says this cost sharing was charged 
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 a $10 
copayment for outpatient diagnostic tests/x-ray services and a $30 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a $10 copayment for outpatient diagnostic tests/x-ray services and a $30 
copayment for physician/practitioner services/specialist. The total amount you are being asked to pay is $40 
copayment ($10 + $30 = $40). This item/service falls within the outpatient diagnostic tests/x-ray services and 
physician/practitioner services/specialist 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 x-ray services and a specialist office visit provided on October 5, 2022.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for all outpatient services, including the respiratory test, provided in
network on October 10, 2022.
You asked the Plan to pay for these services. You say that you went to the facility at night, and they ran tests.
You believe all these services should be covered by the Plan. The Plan denied your request. The Plan says that
part of the services provided, testing to detect respiratory disease (code 0202U), is not a covered benefit.
Maximus upheld the Plans denial. After the decision Maximus found an error and reopened the case file.
Maximus has now determined this case should have been overturned based on Plan directed care as these
services were provided in network at a Plan contract facility.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan must follow these rules. You presented to an in-network facility in the evening for illness as an
outpatient. You relied on your providers direction as to what testing needed to be done to treat you. The file
does not show that the provider or the Plan gave you notice that these services would not be covered. You are
under no obligation to ask a par provider if each test they are giving you would be covered, as you would not
think that was necessary in this type of setting. All the information provided by the Plan regarding the provider
and the treating physician in this case state you were treated in network. Under Medicare rules, this means
these services (minus any applicable copayment) are considered approved by the Plan. Therefore, we decided
that the Plan has to pay for all outpatient services, including the respiratory test, provided by an in-network
provider on October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a higher level of care that 
cannot be provided in home health or a skilled nursing facility. You say that the enrollee requires medical 
management and rehabilitation at least 3 times a week. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) on November 14, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of November 14, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0230) 
provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
October 27, 2022, to November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 requested item or service was exhausted on date of service May 2, 2019. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
October 27, 2022, to November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for high sensitivity C-reactive protein (hsCRP) testing (86141)
provided to the enrollee on May 14, 2021.
You asked the Plan to pay for these services. You say that you would like this reconsidered for payment. The
Plan denied your request. The Plan says that this testing is not appropriate and is considered not reasonable and
necessary.
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.
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 these services have been met.
Insufficient medical records were provided to support payment for code 86141. Therefore, we decided that the
Plan does not have to pay for high sensitivity C-reactive protein (hsCRP) testing (86141) provided to the
enrollee on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee has been on a ventilator for a 
few days, is making slow progress, and will benefit from LTACH services. The Plan denied your request. The 
Plan says LTACH services are not medically necessary. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computer assisted musculoskeletal surgical navigational 
orthopedic procedure, image-guidance based on fluoroscopic image after a hip replacement surgery (0054T), 
provided on September 13, 2022. 
 
You asked the Plan to pay for the computer assisted musculoskeletal surgical navigational orthopedic 
procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
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 pay for the computer assisted musculoskeletal 
surgical navigational orthopedic procedure. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service for the enrollee's clinical 
condition. 
 
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 computer assisted musculoskeletal surgical navigational orthopedic 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the computer 
assisted musculoskeletal surgical navigational orthopedic procedure, image-guidance based on fluoroscopic 
image after a hip replacement surgery (0054T), provided on September 13, 2022.