Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) and a 
topical application of fluoride varnish (D1206) provided on May 25, 2021. 
 
You asked the Plan to pay for a complete series of radiographic images and a topical application of fluoride 
varnish. You say that you contacted the provider's office prior to your appointment and received confirmation 
that they accepted your Plan. You also say that you would have requested a doctor who was in-network had 
you known the provider you saw was not in network. The Plan denied your request. The Plan says the services 
at issue are not a covered benefit with your Plan. 
 
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 a 
complete series of radiographic images (D0210) and a topical application of fluoride varnish (D1206) provided 
on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for remote monitoring of physiologic 
parameters, initial supply of device(s) (99454) provided by an in-network provider on March 31, 2021. 
 
You asked the Plan to waive the copayment for remote monitoring of physiologic parameters. You say that you 
are confused why the Plan says you are being charged $50 for an office visit when the provider has stated they 
billed for a remote monitoring device. The Plan denied your request. The Plan says the claim was 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 $50 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $50 copayment for remote monitoring of physiologic parameters, which falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The actual service 
at issue is the monitoring of the supplied device, rather than the device itself. 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 remote monitoring of physiologic parameters, initial supply of device(s) (99454) 
provided by an in-network provider on March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued stay at a skilled nursing facility (SNF) for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee would 
benefit from continued therapy. The Plan denied your request. The Plan says there has been limited functional 
progress since admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found the 
enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing 
needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a 
plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can 
be provided at a lower 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continued stay at a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are not currently able to get into the 
shower/bath to wash yourself. You state that your spouse has to wash you in the bed, which is degrading when 
you would be able to do this yourself with a shower chair. The Plan denied your request. The Plan says this is 
not a covered item under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 20, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on October 22, 
2019. 
 
You asked the Plan to pay for the resin-based composite. You say that this service should be covered under the 
$2,000 annual maximum allowance for preventive dental services. The Plan denied your request. The Plan says 
benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, restorations (fillings) are limited to two 
procedures per calendar year. The record shows that you received two resin-based composites (D2391 and 
D2392) on October 16, 2019 and your restorations benefit had been exhausted. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite (D2392) provided on October 22, 2019.  
 
Your complaint about the Plan's benefit limitations and dealing with untrained Plan representatives is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99285) and
electrocardiogram (93010) provided on January 30, 2021.
You asked the Plan to pay for the emergency department services and electrocardiogram. You say that you
would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says this
claim is the responsibility of the primary insurance carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer as specified in the decision letter they sent. As the secondary
insurer, the Plan cannot be held responsible for the emergency department services and electrocardiogram until
the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have
to pay for the emergency department services (99285) and electrocardiogram (93010) provided on January 30,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0239U) rendered by the out-of-network (OON) provider on March 6, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis (0239U) rendered by the out-of-network (OON) provider on March 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 8, 2020, to December 14, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee had the 
coronavirus and needed their blood pressure medication. You state that the inpatient hospital stay was not the 
enrollee's fault so they should not be responsible for the charges. The Plan denied your request. The Plan says 
the claims were processed correctly and the enrollee is being charged the correct 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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient hospital stay from December 8, 2020, to December 14, 2020. Therefore, they are 
responsible to pay a $325 copayment for days 1-5 (December 8, 2020, to December 14, 2020). The total 
amount they owe is: $325 (copayment) x 5 (inpatient days) = $1,625.  
 
The enrollee has been asked to the total copayment amount of $1,625 for an inpatient hospital stay. An 
inpatient hospital stay 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 an inpatient hospital stay provided from December 8, 2020, to December 14, 
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told by the hospital that the ambulance would not be allowed to charge you the bill. The Plan denied your request. The Plan says you were charged this cost sharing 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 $200 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $200 for these services. 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 the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87506) provided on April 15, 
2021. 
 
You asked the Plan to pay for infectious agent detection. You say that this is supported in the records. The Plan 
denied your request. The Plan says the records do not support this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the record shows that this 
panel had more than 11 targets. Based on this information, we decided that Medicare rules for coverage of 
infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for 
infectious agent detection (87506) provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital care provided from May 26, 2021, to May 28, 2021, and the subsequent specialist office visit (99213) provided on June 8, 2021.
You asked the Plan to waive the copayments for the inpatient care and office visit. You say that you feel you should not have to pay this cost because the provider's office was unclear regarding what you should owe. The Plan denied your request. The Plan says these claims were processed correctly, and your cost sharing for these services was assessed in accordance with your contract.
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 each medically necessary inpatient hospital admission and a $45 copayment for each in-person visit with a specialist.
You have been asked to pay a $300 copayment for the inpatient care and a $45 copayment for the office visit with a specialist. 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 the inpatient hospital care provided from May 26, 2021, to May 28, 2021, and the subsequent specialist office visit (99213) provided on June 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 30, 
2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on May 1, 2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you feel that the provider was not 
thorough enough. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
May 1, 2021.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat lumbar or sacral epidural injection (64483).
You asked the Plan to pre-approve injection services. You say that this procedure is medically 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 if a prior epidural injection does not provide at least 50% pain relief this repeat procedure is not medically reasonable and necessary. We looked at the file and Medicare rules. There is no documentation provided that the prior epidural injection resulted in less than 50% pain reduction. Based on this information, we decided that Medicare rules for coverage of injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar or sacral epidural injection (64483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for orthodontic treatment provided by an out-of-network 
provider on May 5, 2021. 
 
You asked the Plan to pay for orthodontic treatment. You say that these services are medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for orthodontic treatment provided 
by an out-of-network provider on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) or pay more for the 
prophylaxis (D1110), resin-based composite (D2394), and local anesthesia (D9215) provided on June 1, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the preventive procedure and to pay more for the prophylaxis, resin-based 
composite, and local anesthesia. You say that when you signed up with this Plan you inquired about your 
current doctors and were advised that all of your doctors and dentist were included in the insurance plan. The 
Plan denied your request. The Plan says the preventive procedure is not a covered service.  
 
The Plan also says that these services were performed by a non-participating provider, and you are responsible 
for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. 
The Plan also says that you did not contact the Plan prior to receiving these services to verify provider 
eligibility. 
 
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 unspecified preventive procedure is 
not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% 
coinsurance for each covered dental service, plus the difference between the billed amount and allowed 
amount, when the services are received OON. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999) or pay more for the prophylaxis (D1110), resin-based composite (D2394), and 
local anesthesia (D9215) provided on June 1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335} provided on June 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that resubmitting the claim with supporting documentation to support CPT 99335. Please review and reprocess for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 the domiciliary or rest home visit (99335}
provided on June 8, 2021 by an out-of-network (OON) provider.