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

 
We decided that the Plan does not have to pay for an office visit provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the payment 
denial due to services being rendered in good faith and considered medically necessary. The Plan denied your 
request. The Plan says an authorization was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that additional PT is medically necessary due to 
presence of right artificial hip joint. The Plan denied your request. The Plan says additional PT is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the documentation does not support the need for additional 10 
physical therapy visits. Additional visits are not medically necessary or reasonable based on the review of the 
available documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation of an established patient 
provided on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the EOC is not clear on coverage for an oral 
evaluation. 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 dates of services February 10, 2022, and 
June 10, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation of an 
established patient provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 18, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that on a previous claim from the same 
provider, the same service processed with no copayment which led you to believe that there would be no 
copayment for this service. 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 for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. 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 an injection 
provided on April 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
experienced a severe adverse reaction to the shingles vaccine you received. You also say that due to fear of 
limited medical attention at the hospital, you decided to stay home and be watched by a relative. The Plan 
denied your request. The Plan says your plan covers ambulance transportation only when you are actually 
transported by ambulance. The Plan also says that since you were not transported by this ambulance, the 
service is not covered by your plan. 
 
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 February 2, 2022. 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 the ambulance response and treatment with no 
transport (A0998) provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AllergenEX Allergy testing panel (86003) provided Ma y 
2, 2022. 
 
You asked the Plan to pay for the AllergenEX Allergy testing panel. You say that all services rendered were 
properly ordered by the treating provider and deemed medically necessary for this enrollee per the diagnosis. 
The Plan denied your request. The Plan says this service does not meet the coverage requirements in the 
applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD) 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AllergenEX Allergy testing panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the AllergenEX Allergy testing panel (86003) provided Ma y 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the records reviewed for the proper 
processing of payment. The Plan denied your request. The Plan says the rendering provider is an OON 
provider, and the referral was from a non-participating provider which is not valid. Also, the service rendered 
was not urgent or emergent. 
 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 August 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on August 29, 2022, 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 dental services on June 22, 2022, to August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 August 25, 2021, and 
August 15, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on June 22, 
2022, to August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for folding walker provided on July 16, 2022. 
 
You asked the Plan to waive the copayment for folding walker. You say that you are disputing the share cost 
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 for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for folding walker. This item/service falls within the durable 
medical equipment and related 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 folding walker provided on July 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation - established patient (D0120). 
 
You asked the Plan to pre-approve the dental services. You say that you want to get coverage for your dentist 
who is out-of-network. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation - established patient (D0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for 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 January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $113.52, which is less than the $175 copayment for ultrasound. 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 ultrasound provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an abutment supported porcelain fused to metal 
crown (high noble metal) (D6059 x 2), custom fabricated abutment  includes placement (D6057 x3), and 
crown - porcelain/ceramic (D2740 x2) provided on July 25, 2022. 
 
You asked the Plan to pay the full cost for the dental services. You say that you were advised that the services 
would be covered under your medical benefits because the services were needed due to an accident. 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 July 25, 2022. Therefore, 
we decided that the Plan does not have to pay the full cost for an abutment supported porcelain fused to metal 
crown (high noble metal) (D6059 x 2), custom fabricated abutment  includes placement (D6057 x3), and 
crown - porcelain/ceramic (D2740 x2) provided on July 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for an emergency room visit, 
and Medicare Part B drugs provided from July 2, 2022, to July 3, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for an emergency room visit and Medicare Part B 
drugs. You say that you state the copay is higher than it should be according to her policy. 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 $100 
copayment for Emergency care and a 20% coinsurance for Medicare Part B prescription drugs.  
 
 You have been asked to pay a $100 copayment for an emergency room visit and a 20% coinsurance and 
Medicare Part B drugs. You are being asked to pay a total amount of $165.96 ($100 + 65.96 = $165.96). The 
total allowed amount for Medicare Part B drugs is $329.80. You are only being asked to pay $65.96 ($329.80 x 
20% = $65.96) 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 and coinsurance for an emergency room visit, 
and Medicare Part B drugs provided from July 2, 2022, to July 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for a blood clotting disorder (Factor V 
Leiden and Factor II Prothrombin). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is necessary. The Plan denied 
your request. The Plan says Factor V Leiden and Factor II Prothrombin genetic tests are not covered by 
Medicare, with the exception of pregnant patients with certain conditions. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. The rules say that there is 
insufficient evidence in the published peer-reviewed scientific literature to support coverage for genetic testing 
for inherited thrombophilias outside the pregnant women. Therefore, we decided that the Plan does not have to 
pre-approve genetic testing for a blood clotting disorder (Factor V Leiden and Factor II Prothrombin).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heart procedure provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a heart procedure. You say that this should be covered as it was medically 
necessary. The Plan denied your request. The Plan says 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, the decision is upheld. 
 
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 a heart procedure provided on May 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup, including any pins when required 
(D2950) provided on July 6, 2022, and a crown - porcelain/ceramic tooth #14 (D2740) provided on July 27, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan needs to reimburse you the $503 
which was what the provider would have received from the Plan. 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.  Therefore, we decided that the Plan does not have to pay more for core buildup, including any pins when 
required (D2950) provided on July 6, 2022, and a crown - porcelain/ceramic tooth #14 (D2740) provided on 
July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on January 18, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for
insufficient information in the case file. The Plan requested a reopen and provided additional claim
information. The Plan states that the provider has billed code G0480) with Diagnosis Code R26.81 for
unsteadiness on feet. We found that Local Coverage Article (LCA) A55001 - Billing and Coding: Lab:
Controlled Substance Monitoring and Drugs of Abuse Testing does not include the Diagnosis Code that the
provider has submitted on the appealed claim.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case this claim was
submitted with an inappropriate diagnosis code for this testing. Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the
enrollee on January 18, 2022.