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

 
We decided that the Plan does not have to pay for the office visit provided on August 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that the provider work with the hospital and the facility 
should be responsible for authorization. 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). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 29, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the claim payment denial. 
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). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on September 06, 
2022. 
 
You asked the Plan to waive the copayment for vision care. You say that you disagree with the copaymet. 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 $45 
copayment for vision care. 
 
You have been asked to pay a $45 copayment for vision care. This item/service falls within the vision 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 vision care provided on 
September 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on September 29, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. 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). Therefore, we decided that the Plan does not have to pay for x-rays provided on 
September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic breast ultrasound 
provided on October 06, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic breast ultrasound. You say that you 
would like this waived as you could have gone elsewhere and not had to pay anything. 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 $195 
copayment for other services furnished at a hospital outpatient facility. 
 
You have been asked to pay a $195 copayment for an in-network diagnostic breast ultrasound. This 
item/service falls within the other services furnished at a hospital outpatient facility 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 in-network diagnostic breast ultrasound provided on 
October 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extractions (D7210) and consultation 
(D9310) for tooth #7, #12, #13 provided on October 26, 2022. 
 You asked the Plan to waive the coinsurance for the dental services. You say that you should have a lowered 
copayment for the extractions. The Plan denied your request. The Plan says this cost sharing was charged 
correctly, and it was confirmed that the treating provider is a specialist. 
 
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 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 an 80% coinsurance for 
specialist's usual and customary fee per procedure when receiving specialty services. The total amount charged 
for an extraction was $354 with a coinsurance amount of $283.20 ($354 total amount x 80% coinsurance). The 
total coinsurance amount for the extractions was $849.60 ($283.20 coinsurance x 3 extractions). The total 
amount charged for the consultation was $240 with a coinsurance amount of $192 ($240 total x 80% 
coinsurance). The total coinsurance amount for the dental services was $1,041.60 ($849.60 coinsurance + $192 
coinsurance). 
 
You have been asked to pay a $1041.60 coinsurance for the dental services. This item/service falls within the 
specialist's usual and customary fee per procedure when receiving specialty 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 coinsurance for the extractions (D7210) and consultation (D9310) for tooth 
#7, #12, #13 provided on October 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. You also say that you would like this claim to be reconsidered for processing. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve a complete maxillary denture and a complete mandibular denture. You say that you lost your dentures and cannot eat without them. 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 Plan's coverage rules apply in this case. Maximus overturned the Plan's denial. The Plan requested a reopening and provided documentation to show you have been provided coverage for a complete maxillary denture and a complete mandibular denture within the last five years. 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 November 18, 2019.
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
periodontal maintenance (D4910), and periapical radiographic images (D0220/D0230) provided on September 
27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this provider is not in-network. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. At the 
time of these services, the rendering dentist was out-of-network. Therefore, we decided that the Plan does not 
have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), periodontal maintenance (D4910), 
and periapical radiographic images (D0220/D0230) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, re-cement crown, and a dental 
office visit (D0140, D2920, D9440) provided on October 3, 2022, to October 10, 2022. 
 
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 limited oral evaluations has 
already been exhausted, the cost-sharing applied to the re-cement of a crown applied correctly based on the 
services received, and coverage for the dental office visit denied correctly as it does not fall within your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 October 3, 2022. 
 
You have been asked to pay a 50% coinsurance for the re-cement of a crown (D2920). This item/service falls 
within the dental 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 pay for a limited oral evaluation, re-
cement crown, and a dental office visit (D0140, D2920, D9440) provided on October 3, 2022, to October 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscular testing provided on May 25, 2022. 
 
You asked the Plan to pay for the muscular testing. You say that the services meet guidelines for payment. 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). Therefore, we decided that the Plan does not have to pay for the muscular testing 
provided on May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-rays provided on September 09, 2022. 
 
You asked the Plan to pay for the chest x-rays. You say that the records provided support medical necessity. 
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). Therefore, we decided that the Plan does not have to pay for the chest x-rays 
provided on September 09, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 24, 
2022, to May 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $500 
copayment per day for days 1-4 and a $0 copayment for days 5-90 for inpatient hospital care.  
 
You have been asked to pay a $500 copayment per day for days 1-4 and a $0 copayment for days 5-90 for 
inpatient hospital care. The total amount you are being asked to pay $2,000 ($500 x 4 days = $2,000). 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 inpatient hospital care provided on May 24, 2022, to May 
29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on March 30, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the 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.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $686.80. You are being asked to pay $137.36 ($686.80 x 20% = $137.36).  
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 Medicare Part B prescription drugs provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on May 5, 2022. 
 
You asked the Plan to pay for dental code D9215. You say that you have not met your $3,500 annual maximum 
benefit. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 pay for local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on November 14, 2022. 
 
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 September 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-
ray (D0150, D0210) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140), and dental sales tax (D9985), provided 
on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that these extractions were medically necessary. 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 D7140 was exhausted on date of service June 6, 2022. Dental sales tax cannot be paid 
on services that have been denied. Therefore, we decided that the Plan does not have to pay for extractions 
(D7140), and dental sales tax (D9985), provided on July 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional home health physical therapy visits for the enrollee.
You asked the Plan to pre-approve seven additional home health physical therapy visits. You say that at the time of the appeal, theses visits were medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for seven additional home health physical therapy (PT) visits. The Maximus Physician Reviewer determined that the seven additional PT visits were reasonable and necessary. The Plan requested a reopen and argues the current level of function documents that the enrollee is supervision level of assist with a 3-wheeled walker for transfers, and supervision level of assist to ambulate 125 feet with a three wheeled walker. The Plan notes that the enrollee was approved for two additional visits by the health plan to provide time for completion of the home exercise program following 6 months of home health physical therapy. The Plan further notes that the enrollee is medically stable.
The medical records show that at the time of the appeal the enrollee is a 77-year-old woman with diagnoses that included Parkinson's disease and Alzheimer's dementia. Home health services started on April 18, 2022, and included PT. It is noted that the enrollee is confined because of illness and needs the aid of supportive devices, and that leaving home requires a considerable and taxing effort for the enrollee. On October 7, 2022, the enrollee required assistance for transfers and gait. Three unmet goals were documented: maintaining balance and the ability to get in and out of bed, maintaining ambulation of 125 feet on level surfaces using an assistive device, and maintaining a Tinetti standing balance score of 22/28 or better. Based on the medical records provided, the Plan is correct in this case. The clinical documentation does not clearly document a need for continued PT services. The enrollee had already been educated regarding a home exercise program. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seven additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven additional home health physical therapy visits for the enrollee.