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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 12, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 12, 2022, billed with 
code 99153.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on October 
11, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you cannot afford this 
charge. 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 $10 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $10 copayment for physical therapy visits. This item/service falls within the 
Outpatient rehabilitation 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 
physical therapy visits provided on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography (CT) scan on 
July 20, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are requesting reconsideration. 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 $275 
copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs, 
MRIs, CT scans, PET scans, and hyperbaric oxygen therapy. Covered services include but are not limited to 
other outpatient diagnostic tests. The provider billed in the amount of $900 and the allowed amount is $141. 
This is less than the copayment amount. Therefore, results in the total cost sharing amount of $141.  
 
 
 You have been asked to pay a $141 copayment, which is less than the copayment for CT scan. 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 copayment for computerized tomography (CT) scan on July 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy infusions provided on 
March 29, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy infusions. You say that you had this same 
procedure done last year and you were not charged a coinsurance. 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 Part B prescription drugs. The allowed amount of this drug or item is $903.06, 
resulting in a coinsurance amount of $157.82, which is less than the 20% ($903.06 x 20% = $180.61). 
 
You have been asked to pay $157.82 coinsurance for chemotherapy infusions. 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 
chemotherapy infusions provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specilist visit provided on May 26, 2022. 
 
You asked the Plan to pay for a specilist visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for a specilist visit provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection on April 08, 2022. 
 
You asked the Plan to waive the coinsurance for injection. 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 50% 
coinsurance for out-of-network surgery services at ambulatory surgical center. If you are having surgery in a 
hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an "outpatient." The provider billed in the amount of $19,314.90 and the allowed amount is 
$3,862.98. $3,862.98 x 50% = $1,931.49. Therefore, results in the total cost sharing amount of $1,931.49. 
 
 
 
 You have been asked to pay a 50% coinsurance for injection. This item/service falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for injection on April 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen durable medical equipment 
provided from March 11, 2021, to August 11, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen durable medical equipment. You say that you do not 
believe you have a 20% coinsurance for durable medical equipment. You say that you were not billed each 
month and now you are receiving a bill dating back to 2021. 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 20% 
coinsurance every month for Medicare oxygen equipment.  
 
 
  You have been asked to pay 20% coinsurance every month for oxygen durable medical equipment.  
 
Date of Service Amt Billed Amt Allowed Amt per contract Coinsurance 
3/11/21 $220.00 $136.22 20% Coinsurance $27.24 
3/11/21 $220.00 $44.69 20% Coinsurance $8.94 
4/11/21 $220.00 $136.22 20% Coinsurance $27.24 
4/11/22 $220.00 $44.69 20% Coinsurance $8.94 
5/11/21 $220.00 $136.22 20% Coinsurance $27.24 
5/11/22 $220.00 $44.69 20% Coinsurance $8.94 
6/11/21 $220.00 $47.23 20% Coinsurance $9.45 
7/11/22 $220.00 $47.23 20% Coinsurance $9.45 
7/11/22 $220.00 $143.69  20% Coinsurance $28.74 
8/11/21 $220.00 $143.69  20% Coinsurance $28.74 
8/11/21 $220.00 $47.23 20% Coinsurance $9.45 
9/11/21 $220.00 $143.69 20% Coinsurance $28.74 
9/11/21 $220.00 $47.23 20% Coinsurance $9.45 
10/11/21 $220.00 $47.23 20% Coinsurance $9.45 
10/11/21 $220.00 $143.69  20% Coinsurance $28.74 
11/11/21 $220.00 $143.69  20% Coinsurance $28.74 
11/11/21 $220.00 $47.23 20% Coinsurance $9.45 
12/11/21 $220.00 $143.69 20% Coinsurance $28.74 
12/11/21 $220.00 $47.23 20% Coinsurance $9.45 
1/11/22 $220.00 $151.15 20% Coinsurance $30.23 
1/11/21 $220.00 $48.39 20% Coinsurance $9.68 
2/11/22 $220.00 $151.15 20% Coinsurance $30.23 
2/11/22 $220.00 $48.39 20% Coinsurance $9.68 
3/11/22 $220.00 $151.15 20% Coinsurance $30.23 
3/11/22 $220.00 $48.39 20% Coinsurance $9.68 
4/11/22 $220.00 $151.15 20% Coinsurance $30.23 
4/11/22 $220.00 $48.39 20% Coinsurance $9.68 
5/11/22 $220.00 $48.39 20% Coinsurance $9.68 
5/11/22 $220.00 $151.15 20% Coinsurance $30.23 
6/11/22 $220.00 $151.15 20% Coinsurance $30.23 
6/11/22 $220.00 $48.39 20% Coinsurance $9.68 
7/11/22 $220.00 $48.39 20% Coinsurance $9.68 
7/11/22 $220.00 $151.15 20% Coinsurance $30.23 
8/11/22 $220.00 $151.15 20% Coinsurance $30.23 
8/11/22 $220.00 $48.39 20% Coinsurance $9.68 
 
 
This item/service falls within the oxygen equipment 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 oxygen durable medical equipment provided from March 11, 2021, to August 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on July 3, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you disagree with the 
copayment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service 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 room visit 
provided on July 3, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 7, 2021.
You asked the Plan to pay for this claim. You say that this testing should be covered by the Plan., The Plan denied your request.
The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted that the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The records show the specimen was collected on October 26, 2021, rather than the billed date of service November 7, 2021. The date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid due to a discrepancy with the date of service and the date the specimen was collected. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided to the
enrollee on January 21, 2022.
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by
Medicare. The Plan denied your request. The Plan says that the claim was billed with a date of service
inconsistent with Medicare rules governing laboratory services.
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the
specimen was collected.
We looked at the file and Medicare rules. The file indicates that the DOS of the test is not the same as the date
the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the
F1CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the
FoundationOne CDx (F1CDx) testing provided to the enrollee on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
Tooth #22, 23, 25, 26, 27 and 28, pontic - porcelain/ceramic (D6245) #24 and retainer crown - 
porcelain/ceramic (D6740) for Tooth #22, 23, 25, 26, 27 and 28. 
 
You asked the Plan to pre-approve dental services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested D6740/D6245 are only approvable when one tooth is missing 
in one side of an arch. The service will not restore the function of his mouth correctly. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our physician reviewer 
found the reason for the denial was that the service is not a covered expense as per the plan. A fixed bridge may 
be covered to replace two adjacent mandibular anterior teeth if there are no posterior teeth missing. In this case 
a single mandibular tooth (#24) is to be replaced and there are missing posterior mandibular teeth. Also note 
that tooth #28 appears to be missing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve core buildup, including any pins when required (D2950) Tooth #22, 23, 25, 26, 27 and 28, 
pontic - porcelain/ceramic (D6245) #24 and retainer crown - porcelain/ceramic (D6740) for Tooth #22, 23, 25, 
26, 27 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7473, D9310, D9612, D5899, D7510, 
D7310) provided on July 17, 2021. 
 
You asked the Plan to pay 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 your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record  
  shows your benefit for the requested item or service was exhausted on date of service 07/17/2021. Therefore, 
we decided that the Plan does not have to pay for dental services (D7473, D9310, D9612, D5899, D7510, 
D7310) provided on July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit option for a manual wheelchair. 
 
You asked the Plan to pre-approve the transit option for a manual wheelchair. You say that this equipment is 
necessary for leaving the house. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan as it does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the transit option for a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) tooth 21, core 
buildup, including any pins when required (D2950) and endodontic therapy, premolar tooth (excluding final 
restoration) (D3320). 
 
You asked the Plan to pre-approve dental services. You say that you have a maximum benefit, and you are in a 
lot of pain and discomfort. 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. Crown - porcelain/ceramic 
(D2740) tooth 21, core buildup, including any pins when required (D2950) and endodontic therapy, premolar 
tooth (excluding final restoration) (D3320) are not covered under the Plans dental benefits. 
 
  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 pre-approve 
crown - porcelain/ceramic (D2740) tooth 21, core buildup, including any pins when required (D2950) and 
endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontal procedure (D4999). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs this dental procedure 
done. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the periodontal procedure is not covered by the 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
periodontal procedure (D4999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mirena intrauterine device (IUD). 
 
You asked the Plan to pay for Mirena IUD. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
Mirena intrauterine device (IUD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on April 4, 
2022, to June 13, 2022 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
copayment. 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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for each date of service. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visits provided on April 4, 2022, to June 13, 2022