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

We decided that the Plan does not have to pay for a rebase complete mandibular denture (D5711) provided by
an out-of-network provider on July 26, 2021.
You asked the Plan to pay for a rebase complete mandibular denture. You say that you were told that this
would be covered. The Plan denied your request. The Plan says D5711 is not a covered dental benefit.
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 rebase
complete mandibular denture (D5711) provided by an out-of-network provider on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient services provided by on July 27,
2021.
You asked the Plan to waive the copayment for the outpatient services. You say that you have already paid the
copayment that the Plan asked you to pay, and you did not receive this service. The Plan denied your request.
The Plan says the claim was processed correctly, and the copayment applied was less than the normal
copayment for this service.
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 Medicare-covered outpatient hospital and observation services. The total amount allowed was
$234.56 which is less than the copayment amount of $325. Therefore, only $234.56 was billed for the
copayment.
You have been asked to pay a $234.56 copayment for outpatient services. The outpatient services falls within
the Outpatient hospital 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 the copayment for
outpatient services provided by on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig (A9282), purchased on July 17, 2021, and July 30, 2021.
You asked the Plan to pay for the wig. You say that you need this item. The Plan denied your request. The Plan says your request is not a covered benefit because wigs are not primarily and customarily used to serve a medical purpose, they are useful in the absence of illness or injury and they do not replace the function of an internal body organ.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the wig (A9282), purchased on July 17, 2021, and July 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the purchased portable Inogen One G5 Oxygen Concentrator
provided on July 7, 2021.
You asked the Plan to pay for the purchased Inogen One oxygen system. You say that you would like the Plan
to reconsider your request. The Plan denied your request. The Plan says the denial of payment for these items is
correct because purchased oxygen equipment is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for
coverage and purchased oxygen equipment is statutorily non-covered.
We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided
that the Plan does not have to pay for the purchased portable Inogen One G5 Oxygen Concentrator provided on
July 7, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room (ER) visit with injection of ketorolac and
dexamethasone provided on June 28, 2021.
You asked the Plan to pay for the ER visits and drug injections. You say that this was denied in error. The
records support that these services were rendered. The Plan denied your request. The Plan says that our records
indicate the provider did not perform this service. Therefore, no benefit is available to this provider.
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 has failed to provide a valid denial rationale for this claim. The denial
states that the provider did not perform the billed services, meaning that no payment can be made. No details
were provided to clarify the basis on which the Plan made this determination. The provider submitted medical
records that clearly show that the enrollee was seen at the facility for an emergency visit and received the drugs
as treatment. Without a rationale that can be confirmed, we find that the denial is not supported in this case.
Therefore, we decided that the Plan has to pay for the emergency room (ER) visit with injection of ketorolac
and dexamethasone provided on June 28, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Epidurography (72275) provided on May 6, 2021.  You asked the Plan to pay for code 72275. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72275 is a column II code to column I code 64483. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Epidurography (72275) provided on May 6, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services received on September 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
decision. The Plan denied your request. The Plan says that the claim has been processed correctly per your plan
benefits.
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 rules also 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.
You were provided the laboratory services by a contract provider. The file does not show that the Plan provided
notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory
services is considered approved by the Plan. In addition, the Plan has not made reasonable and diligent efforts
to gather and forward to us information regarding their decision to deny your request. Review of the file shows
that the entire Evidence of Coverage (EOC) that explains your cost share requirements such as your deductible
was not provided to Maximus for review. This also means the Plan did not substantiate their denial. Therefore,
we decided that the Plan has to pay for the laboratory services received on September 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) provided on January 13, 2020.
You asked the Plan to pay for initial hospital care. You say that you would like this claim reprocessed based on
timeliness. The Plan denied your request. The Plan says this claim has not been filed within Medicare timely
filing limits.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for initial hospital care was not filed until July 14, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for initial hospital care (99223) provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274) provided on August 25, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that there is a 30% coinsurance for out of network preventive dental services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than the plan pays.
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 and the services are covered, out of
network dentists may bill you for the difference between the allowed amount and the billed amount. Therefore,
we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation
(D0150), prophylaxis (D1110), bitewing x-rays (D0274) provided on August 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy services (92507) provided on April 6,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for speech therapy. You say that these services were necessary and at the time the
enrollee's full insurance information was not provided. You did not realize prior authorization was necessary.
The Plan denied your request. The Plan says out-of-network care is only covered in certain limited
circumstances. The services in this case were not urgent or emergent, nor were they pre-approved or referred
by a contracted provider.
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 speech therapy services (92507) provided on
April 6, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the surgical extraction. You say that you had been to this provider before the pandemic and the services were covered. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that the provider is non-participating 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. The only type of extractions that are covered under your dental benefit are simple extractions. The contract also says that dental services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 17, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on September 15, 2021  You asked the Plan to waive the copayment for the outpatient clinic visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided, the providers confirmed with the Plan that there was a sign on the front desk that stated the fee that would be charged.  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 hospital services.      You have been asked to pay a $128.35 copayment for an outpatient clinic visit, which is less than the $325 stated in the Plan's contract. Outpatient clinic visits fall within the Outpatient hospital 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 the copayment for an outpatient clinic visit provided on September 15, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 2), panoramic x-ray (D0330), and oral photographic image (D0350) provided on October 6, 2021.  You asked the Plan to pay for the dental services. You say that your provider failed to tell you that you were not covered for some procedures. You say that you called them numerous times to make sure they were in your plan's network. You also say that you were told you were covered 100%. The Plan denied your request. The Plan says the periapical x-rays, panoramic x-ray, and oral photographic image are not listed as covered services.  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 periapical x-rays, panoramic x-ray, and oral photographic image are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 2), panoramic x-ray (D0330), and oral photographic image (D0350) provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on
July 6, 2021.
You asked the Plan to pay for the monitor. You say that this was medically necessary. The Plan denied your
request. The Plan says the documentation submitted did not sufficiently support the billed supply code; nor did
the documentation indicate that the provider discussed the need for the billed supply code.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the monitor. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, there is no documentation that the enrollee is injecting insulin three or more times a
day. The records indicate the enrollee is using 70/30 insulin twice daily. The records do not document that the
enrollee is making frequent insulin dosage adjustments on the basis of testing results.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pay for a continuous glucose monitor provided to the enrollee on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on July 22, 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 office visit (99204) rendered by the out-of-network (OON) provider on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from August 20, 2021, to September 15, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says custodial care is not covered.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing
needs. The enrollee did not have documented skilled therapy needs. The enrollee was ambulating 100 feet,
navigating stairs and tending to ADLs with minimal supervision. Daily skilled services were not required to
establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care
needs, as a practical matter, could 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 pay for skilled nursing facility (SNF) services provided to the enrollee from August 20, 2021, to
September 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of extracranial arteries;
complete bilateral study (93880) provided July 21, 2021.
You asked the Plan to waive the copayment for the ultrasound of both sides of head and neck blood flow. You
say that you feel this was emergency care and the copayment should be waived. The Plan denied your request.
The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a
physician's office or at a free-standing facility.
You have been asked to pay a $110 copayment for the ultrasound of both sides of head and neck blood flow.
The ultrasound of both sides of head and neck blood flow 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
the duplex scan of extracranial arteries; complete bilateral study (93880) provided July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the lumbar spine (72148) provided on August 31, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $135
copayment for each Medicare-covered magnetic resonance imaging (MRI) scan, computed tomography (CT)
scan, and positron emission tomography (PET) scan.
You have been asked to pay a $135 copayment for the Medicare-covered MRI scan of the lumbar spine
provided. On this day, two MRI diagnostic tests were provided to you. The Plan contract states that you must
pay a $135 copayment for each Medicare-covered MRI diagnostic test. 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 magnetic resonance imaging (MRI) of the lumbar spine (72148) provided on August 31,
2021.