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

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on October 28, 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 (99214) rendered by the out-of-network (OON) provider on  
October 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on November 8, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were having 
chest pain and did not feel well. You say the visiting nurse that was at your home advised you to call 911 and 
when the ambulance arrived you declined being transported to the hospital as you had recently been discharged 
from the hospital and did not want to go back to the hospital. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary occurs, then there 
is no Medicare covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on November 8, 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 
September 5, 2021, to September 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as they would cause a financial burden. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services 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 $350 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,050 copayment for 3 days of inpatient hospital care. 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 inpatient hospital stay provided from September 5, 2021, to September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110). 
 
You asked the Plan to pre-approve the complete upper denture. You say that you would like reconsideration 
because your dentures cracked and are causing you pain. The Plan denied your request. The Plan says this 
exceeds the frequency limitation. 
 
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 dentures exceed the 
frequency limitation as explained in the Plan's EOC. Specifically, the record shows that you received complete 
upper dentures in January 2021. Complete upper dentures are covered once every 5 years. Therefore, we 
decided that the Plan does not have to pre-approve the complete upper denture (D5110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
recent physical therapy notes, you appear to be functioning much better now and has reached the stage where 
unsupervised home exercises should be sufficient to maintain the benefits of the previous physical therapy 
sessions, whereas there was insufficient support made for additional physical therapy at this time. Therefore, 
this request for additional home physical therapy will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on October 20, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the walker. You say that you were informed by your doctor to buy the walker 
where it was available and then submit for reimbursement. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advance. 
 
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 walker provided on October 20, 2021, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay services provided outside of the United States from April 7, 2020, to May 19, 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 you did not follow your Plan contract rules when obtaining these
services. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.

The Plan is correct in this case. Medicare says that plans must pay for emergency and urgently needed services
for eligible enrollees. The Plan contract says that while outside of the service area, coverage is limited to
emergencies, urgently needed care, renal dialysis and pre-approved care. The Plan contract also says they must
end your membership if you are away from the service area for more than six months. You did not follow your
Plan contract rules when you obtained these services. You also were away from your service area well beyond
the six months allowed in the Plan contract. Therefore, we decided that the Plan does not have to pay for out of
country services provided outside of the United States from April 7, 2020, to May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you are in pain and need assistance with 
activities of daily living. The Plan denied your request. The Plan says there is no valid physician order or plan 
of care. 
 The Plan must follow Medicare rules. Medicare rules say that home health services are covered when a 
beneficiary is receiving services under a plan of care established and reviewed by a physician. 
 
We looked at the file and Medicare rules. The file shows that there is no physician order or plan of care 
submitted for these services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide 
services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that you want to go to the out-of-network 
physical therapy that was recommended by your friend as they can help you with the situation with your legs. 
The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided 
that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from November 15, 2021, 
to November 22, 2021. 
 
You asked the Plan to pay for the SNF care. You say that it is felt that the facility failed to obtain authorization 
for necessary care. This stay should be covered. The Plan denied your request. The Plan says that the enrollee 
should have remained at the inpatient rehabilitation facility as she had not completed her full course of 
treatment there. 
 
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 pay for the SNF care. Our reviewer says that the 
services provided during this date span met Medicare coverage rules for SNF care. Our physician reviewer 
found the enrollee is an 88-year-old woman who was admitted to the acute care hospital on 10/19/21 with a 
stroke. The enrollee was admitted to an Inpatient Rehab Facility on 10/25/21. The enrollee had cognitive 
deficits and left hemiplegia. The enrollee was max to total assist for bed mobility and transfers. On 11/11/21 it 
is documented that the enrollee was gait training on parallel bars, was transferring with maximal assistance, 
and it was noted that endurance could be a barrier at times.  
 
The documentation supports that it was medically reasonable and necessary to provide skilled services on a 
"daily basis" on an inpatient basis, in a skilled nursing facility setting from 11/15/21 through 11/22/21. 
 
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 SNF care have been met. Therefore, we decided that the Plan has to pay for 
skilled nursing facility (SNF) care provided from November 15, 2021, to November 22, 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: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay services provided outside of the United States from April 7, 2020, to December
29, 2020.

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 you did not follow your Plan contract rules when obtaining these
services. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.

The Plan is correct in this case. Medicare says that plans must pay for emergency and urgently needed services
for eligible enrollees. The Plan contract says that while outside of the service area, coverage is limited to
emergencies, urgently needed care, renal dialysis, and pre-approved care. The Plan contract also says they must
end your membership if you are away from the service area for more than six months. You did not follow your
Plan contract rules when you obtained these services. You also were away from your service area well beyond
the six months allowed in the Plan contract. Therefore, we decided that the Plan does not have to pay for out of
country services provided outside of the United States from April 6, 2020, to December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional endodontic therapy services (D3310, 
D3320), 4 additional restorative services (D2954), and 4 additional crowns (D2750). 
 
You asked the Plan to pre-approve 5 additional endodontic therapy services, 4 additional restorative services, 
and 4 additional crowns. You say that you need these services. The Plan denied your request. The Plan says 
these services exceed the benefit limits of your contract. 
 
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 covers 2 endodontic 
therapy services coded as D3310-D3330 per calendar year, 3 restorative services coded as D2950-D2954 per 
year, and 3 crowns coded as D2710-D2792 or D6210-D6792 per year.  
  
We looked at the file and Medicare rules. The record shows that you have been approved for 2 endodontic 
therapy services, 3 restorative services, and 3 crowns during this calendar year, meeting the Plans benefit 
limits for these services. Based on this information, we decided that the Plan's rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 5 additional endodontic therapy services 
(D3310, D3320), 4 additional restorative services (D2954), and 4 additional crowns (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay services provided outside of the United States from April 14, 2020, to December
31, 2020.

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 you did not follow your Plan contract rules when obtaining these
services. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information.

The Plan is correct in this case. Medicare says that plans must pay for emergency and urgently needed services
for eligible enrollees. The Plan contract says that while outside of the service area, coverage is limited to
emergencies, urgently needed care, renal dialysis and pre-approved care. The Plan contract also says they must
end your membership if you are away from the service area for more than six months. You did not follow your
Plan contract rules when you obtained these services. You also were away from your service area well beyond
the six months allowed in the Plan contract. Therefore, we decided that the Plan does not have to pay for out of
country services provided outside of the United States from April 14, 2020, to December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 24, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. 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 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 $75 
copayment for Ambulance.  
 
 
  You have been asked to pay a $75 copayment for the ambulance transportation. 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 ambulance transportation provided on October 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy visits (77401) and office 
visit provided from August 2, 2021, to August 26, 2021. 
 
You asked the Plan to waive the copayment for the radiation therapy visits and office 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 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 $60 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies and a $35 copayment for 
Physician/Practitioner Services, Including Doctors Office Visits. You have been asked to pay a $434.18 copayment for ten radiation therapy visits and 1 office visit, which is 
less than the standard $60 copayment per visit. 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 radiation 
therapy visits (77401) and office visit provided from August 2, 2021, to August 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
29, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the service sshould be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
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 $30 
copayment for Urgently needed services.  
 
 
  You have been asked to pay a $30 copayment for an urgent care visit. 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 urgent care visit provided on October 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on November 18, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the plan should cover these charges. 
The Plan denied your request. The Plan says the copayment amount charged is correct. 
 
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 Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility (such as radiology center or medical clinic).  
 You have been asked to pay $136.75, which is less than the Plan's EOC documented $150 copayment for a CT 
scan. CT scans fall 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 computed tomography (CT) scan provided 
on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 provided on October 25, 2021 by an 
out-of-network (OON) provider.