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

 
We decided that the Plan does not have to pay for office visit provided on June 10, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing claim payment denial for services 
rendered. The Plan denied your request. The Plan says If the enrollee needs Medicare-covered medical care and 
a network provider is unable to provide this care, you may be able to get care from an out-of-network provider. 
Our plan must confirm there is not a network provider available, and the out-of-network provider must contract 
the plan to request an authorization for you to obtain services. If approved, the out-of-network provider will be 
issued an authorization to provide the service(s).  
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 office visit provided on June 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cardiac procedure provided on February 
16, 2022. 
 
You asked the Plan to waive the coinsurance for a cardiac procedure. You say that you are appealing because 
this was an emergency. You couldnt move your body. So, the ambulance took you to the facility because you 
had a stroke. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of this 
service or item is $9871.19, resulting in a coinsurance of $1974.24 ($9871.19 x 20% = $1974.24). 
 
You have been asked to pay a $1974.24 coinsurance for a cardiac procedure. This item/service 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 coinsurance for a cardiac procedure provided on February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on May 10, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs. The provider billed in 
the amount of $13,077 and the allowed is $1,414.02. $1,414.02 x 20% = $282.80. Therefore, results in the total 
cost sharing amount of $282.80. 
 
You have been asked to pay a 20% coinsurance for injections. This item/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 injections on May 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmological examination provided on March 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ophthalmological examination. You say that this should have been covered. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an OON provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 an ophthalmological examination provided on 
March 28, 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 an office visit and knee x-rays provided on March 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and x-rays. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
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 an office visit and knee x-rays provided on March 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 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 health plan. The health 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the 2D oral/facial images (D0350). We decided that the Plan does not 
have to pay for the porcelain/ceramic crowns (D2740), gingival irrigation (D4921) and unspecified periodontal 
procedure (D4999).  
 
You asked the Plan to pay for 2D oral/facial images (D0350), porcelain/ceramic crowns (D2740), gingival 
irrigation (D4921) and unspecified periodontal procedure (D4999). You say that payment was denied for all 
three appointments required to evaluate the need for, prepare for and apply the crowns. The Plan says that the 
dental services received are not covered benefits. 
 
We decided that the Plan has to pay for the 2D oral/facial images (D0350).  
 
The Evidence of Coverage clearly states that routine dental benefits are included for all enrollees in this plan 
and cover in-network only diagnostic and preventive services. 2D oral/facial images (D0350) is listed as a 
covered routine dental benefit. Therefore, we decided that the Plan has to pay for 2D oral/facial images 
(D0350) provided on June 2, 2022.  
 
We also decided that the Plan does not have to pay for porcelain/ceramic crowns (D2740), gingival 
irrigation (D4921) and unspecified periodontal procedure (D4999). 
 
The porcelain/ceramic crowns (D2740) received were for molar teeth. The Evidence of Coverage clearly states 
that only base metal materials are covered for crowns on molar teeth. In addition, gingival irrigation (D4921) 
and unspecified periodontal procedure (D4999) are not listed as a covered routine or optional dental benefit. 
Therefore, we decided that the Plan does not have to pay for gingival irrigation (D4921) and unspecified 
periodontal procedure (D4999) provided on June 9, 2022, and June 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for odontoplasty services (D9971) provided on August 23, 2021 
by an out-of-network provider 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for odontoplasty services (D9971) provided on August 23, 2021 by an out-of-network provider
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed for date of service October 13, 
2021. 
 You asked the Plan to pay for laboratory services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the codes at issue are included in other billed 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500; that code 87481 
is a column II code to column I codes 87150 and 87801; that code 87640 is a column II code to column I codes 
87150, 87641 and 87801; that code 87653 is a column II code to column I codes 87150 and 87801; that code 
87798 is a column II code to column I codes 87150 and 87801; and that code 87641 is a column II code to 
column I codes 87150 and 87801. However, the column II codes at issue were billed with modifier 91 to 
bypass these edits. 
 
We asked our coder 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 laboratory services. Our reviewer says that the services at 
issue do not meet criteria for payment. Our reviewer found that the use of modifier 91 with the procedure codes 
at issue to bypass the mutually exclusive edits is not supported in the available medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services billed for date of service October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99072 billed for date of service December
13, 2021.

You asked the Plan to pay for procedure code 99072. You say that you disagree with the denial. The Plan
denied your request. The Plan says procedure code 99072 is considered bundled and not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate procedure code.

We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 99072 billed for date of service December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness and electronic connection, power elevating leg rests, shoe holder, and mud guards. 
 
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 not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that durable medical equipment for use outside the home is not covered. 
 
The requested power seat elevation system does not serve a purpose that is primarily medical in nature and is 
not covered. The requested mud flaps are for use outside of the home and Medicare does not cover equipment 
for this use. The requested expandable controller with harness and electronic connection are not needed to 
control the approved power options. The shoe holder is not covered because shoe holders are included in the 
approved equipment. The footrests are not covered because there is no documentation that you are unable to 
use the approved footrests.   
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable 
controller with harness and electronic connection, power elevating leg rests, shoe holder, and mud guards.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter device.

You asked the Plan to pre-approve an oximeter device. You say that this is necessary for your condition. The
Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that oximeters (E0445) and replacement probes
(A4606) will be denied as non-covered because they are monitoring devices that provide information to the
treating practitioner to assist in managing the beneficiary's treatment. Based on this information, we decided
that Medicare rules for coverage of an oximeter device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an oximeter device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation, per site 
(D7953) for tooth #6. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs these requested services. 
The Plan denied your request. The Plan says this service is not covered under your 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 bone replacement graft 
for ridge preservation, per site (D7953) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve bone replacement graft for ridge preservation, per site (D7953) for 
tooth #6.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee demonstrates a need for IRF services. The Plan denied your request. The Plan says the request 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 enrollee's 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for a crown (D2740) provided on March 24, 2022. 
 
You asked the Plan to pay more for a crown. You say that you had approval on file last year for two crowns, 
but one had to wait due to financial hardship. You say that this should be covered since it was approved before. 
The Plan denied your request. The Plan says that the claim processed to pay for the least costly method of 
treatment. 
 
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 follows these rules. 
 
The records show you received the crown from a contract provider. The file does not show that the Plan 
provided notice that this type of crown would not be covered. Under Medicare rules, this means this crown is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay 50% of the allowed amount of 
the porcelain/ceramic crown (D2740) provided on March 24, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a crown and intraoral x-ray (D2740, D0220) provided 
on May 18, 2021 by a non participating provider. 
 
You asked the Plan to reimburse 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 the dental services were received from an 
Medicare opt-out provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to reimburse for a crown and intraoral x-ray (D2740, D0220) provided on May 18, 2021 by a non-participating 
provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the mental health services provided from September 18, 2018, through 
October 16, 2018. 
 
You asked the Plan to pay for the mental health services. You say that these services were previously approved. 
There is no reason that these other dates should not also be covered. The Plan denied your request. The Plan 
says that your appeal was denied as there was no good cause for filing the appeal untimely. 
 
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. The Plan originally dismissed your appeal request as untimely on February 8, 
2022. You subsequently requested the Plan to vacate this dismissal, and the Plan did so on June 10, 2022, and 
indicated a substantive review would be performed. It appears that this did not occur as the Plan then forwarded 
the case to Maximus stating that payment was denied as there was no good cause for untimely filing. This is 
not a valid substantive decision. The Plan cannot vacate a dismissal then deny the appeal for the same reason as 
it was originally dismissed. The Plan did not attempt to receive any medical records from the provider, and as 
such, Maximus cannot review whether criteria may have been met. Since there is no valid denial rationale, we 
find that this must be covered by the Plan. Therefore, we decided that the Plan has to pay for the mental health 
services provided from September 18, 2018, through October 16, 2018.  
 
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.