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

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 8, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diclofenac Gel 3%. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part b. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Diclofenac Gel 3%.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (code D0364) you 
received on December 14, 2021. 
 
You asked the Plan to pay for the cone beam computed tomography (code D0364). You say that this service 
was necessary because you had a large cavity below the gum line and it was only visible with this test. The 
Plan denied your request. The Plan says this service is not covered under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's dental benefit 
includes coverage only for those dental services explicitly listed in Schedule A of your 2021 Dental Benefits 
chart. Cone beam computed tomography (code D0364) is not listed as a covered service in this chart.  This 
means that this service is not covered for any reason. 
 
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 cone 
beam computed tomography (code D0364) you received on December 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for out of area services provided on August 30, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says that this provider was not in network. Maximus upheld the Plans
denial. Upon further review, Maximus reopened the case due to a process error.
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. There were no medical records submitted with the case file that
would allow us to determine this situation was not urgent our emergent while out of area and/or out of network.
Therefore, we decided that the Plan has to pay for out of area x-rays of the ankle provided on August 30, 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 must 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 waive the copayment for inpatient hospital care provided from 
September 9, 2021, to September 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the cost sharing should be 
waived due to the enrollee's COVID-19 diagnosis. The Plan denied your request. The Plan says the enrollee 
was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for each inpatient admission, up to a yearly maximum of $900.  
 
The file does not show evidence that cost share waivers for COVID-19 were in effect during this time. 
Therefore, the enrollee has been asked to pay a $300 copayment for the inpatient care. The inpatient care falls 
within the Inpatient Hospital Care 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 
copayment for inpatient hospital care provided from September 9, 2021, to September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the administered drug (J7326) provided on 
November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the administered drug. You say that you would like this 
coinsurance waived. The Plan denied your request. The Plan says the claim has 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 clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total cost share of $107.47 for the administered drug ($537.36 Medicare allowed 
amount x 20% coinsurance). This service falls within the Medicare Part B prescription drugs benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the administered drug (J7326) provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic X-ray services (D0330), prophylaxis (D1110) 
and comprehensive oral evaluation (D0150) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim further paid. The Plan 
denied your request. The Plan says the claim for dental services has processed correctly per the Plan's contract. 
 
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 the dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. In this case, payment has already been made within the last 5 years 
for panoramic X-rays exceeding the Plan's benefit level. In addition, the Plan has paid for the prophylaxis and 
comprehensive oral evaluation services based on their contractual obligation. The Plan has paid the 
Medicare-allowed among for these services. You are responsible for the difference between what the out-of-network 
provider charged and this Medicare-allowed amount. Based on this information, we decided that the Plan's 
rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have 
to pay for the panoramic X-ray services (D0330), prophylaxis (D1110) and comprehensive oral evaluation 
(D0150) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided by a participating 
provider on February 14, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you were never told this service was not 
covered. The Plan denied your request. The Plan says the rendered service is not a covered benefit. 
 
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 (D4921) provided by a participating provider on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 19, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
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, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on September 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on December 7, 
2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you do not have the money to pay 
for the bill. 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 $325 
copayment for outpatient services that are not provided at ambulatory surgical centers.  
 
You have been asked to pay a $325 copayment for the endoscopy. The endoscopy 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 waive the copayment for an endoscopy performed on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite filling (code D2391) you received 
on January 10, 2022. 
 
You asked the Plan to pay for the resin-based composite filling. You say that this should be covered because 
the filling was needed in a front-facing tooth. The Plan denied your request. The Plan says this service is not 
covered under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's dental benefit 
includes coverage only of those dental services explicitly listed in your dental benefits chart. Fillings coded as 
D2391 are not listed as covered, regardless of the reason or need for the service. 
 
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 resin-
based composite filling (code D2391) you received on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on January 21, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that this was necessary because you 
were a new patient. The Plan denied your request. The Plan says the benefit limit for these services were 
already met and 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. The Plan covers one 
comprehensive oral evaluation every three years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on January 11, 2021. Based on this information, we decided that the Plan's rules for coverage of a 
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance rendered on March 16, 2022. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal maintenance rendered on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100, 99140) provided on February 
7, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says these codes have not been billed as 
required by Medicare coding regulations. 
 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 codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99140 area not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services (99100, 99140) provided on February 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
spine provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the EOB you received shows you owe 
$0. 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 $250 
copayment for each diagnostic radiology services, such as MRI's.  
 
You have been asked to pay a $250 copayment for the MRI. The MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and 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 copayment 
for a magnetic resonance imaging (MRI) of the spine provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for leg prosthetic supplies provided on 
January 13, 2022. 
 
You asked the Plan to waive the coinsurance for the prosthetic supplies. You say that you have not had to pay 
for the supplies in the past. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for prosthetic devices and related supplies. 
 
Item Allowed Amount 20% Coinsurance 
Protective Cover Below Knee $476.08 $95.22 
Prosthetic Sock $32.44 $6.49 
Molded Cushion $164.66 $32.93 
Total:  $134.64 You have been asked to pay $134.64, which is 20% of the allowed amount for the prosthetic supplies. The 
prosthetic supplies fall 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 leg prosthetic supplies provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection procedure performed on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the injection procedure. You say that you had the procedure 
done in the pain clinic. 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 $365 
copayment for surgery or services provided at an outpatient hospital.  
 
The file shows that the billed location code reflects an outpatient hospital facility. Therefore, you have been 
asked to pay a $365 copayment for the injection procedure. The injection procedure 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 waive the copayment for a back injection procedure performed on 
February 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided on November 19, 2021. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that you are 
on a fixed income and cannot afford the bill. 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 $150 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 or reduce the 
copayment for ambulance transportation provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar spinal surgery. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 inpatient rehabilitation facility (IRF) admission and services.