Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that you feel you truly need this 
item. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the documentation does not support that the requested portable oxygen concentrator is 
medically reasonable or necessary. Our physician reviewer found you have a stationary oxygen concentrator 
and portable tanks.  You have difficulty handling the portable tanks. However, there is no documentation that 
oxygen saturation can be maintained greater than 91% during exertion while using an oxygen conserving 
device. There is no documentation of need in the medical record. Therefore, you do not meet criteria for the 
requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on February 1, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied 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 20% 
coinsurance for oxygen equipment. The total allowed amount of the oxygen equipment for claims 
220209780466 and 220211783021 is $160.02, resulting in a coinsurance amount of $32. 
 
You have been asked to pay a 20% coinsurance for oxygen equipment. Oxygen equipment 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 equipment 
on February 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hepatitis B vaccine provided on October 27, 2021, and November 
23, 2021. 
 
You asked the Plan to pay for the hepatitis B vaccine. You say that you would like the Plan to reconsider their 
denial as you meet Medicare criteria. The Plan denied your request. The Plan says that the services are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. The Plan follows these rules. 
 
You were referred for the hepatitis B vaccine by a contract provider. The file does not show that the Plan 
provided notice that the hepatitis B vaccine would not be covered in your case. The hepatitis B vaccine is 
covered for enrollees who are in a high to medium risk position of employment. The Plan has not submitted a 
clear reason why your employment does not fall under this umbrella of coverage. Under Medicare rules, this 
means the hepatitis B vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for the hepatitis B vaccine provided on October 27, 2021, and November 23, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, retroperitoneal (76775) provided on 
December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the retroperitoneal ultrasound. You say that you feel the service should be 
covered. The Plan denied your request. The Plan says this service is not covered because it was provided OON 
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 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 ultrasound, retroperitoneal (76775) provided 
on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances for a practitioner service with ultrasound 
guidance and an injection on February 16, 2022. 
 
You asked the Plan to waive the coinsurances for a practitioner service with ultrasound guidance and an 
injection. You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the 
cost share applied 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 two 15% 
coinsurances and a $110 deductible for a practitioner service with ultrasound guidance and an injection. The 
total allowed amount of the two services provided is $99.18.  The members combined in-network and out-of-
network medical deductible is $110 and hadnt been met; therefor, the allowed amount of $99.18 is the amount 
owed by the enrollee.  
You have been asked to pay two 15% coinsurances and a $110 deductible for a practitioner service with 
ultrasound guidance and an injection. Practitioner services with ultrasound guidance and an injection fall within 
the Physician/practitioner services, including doctors office visits and the Medicare Part B prescription drugs 
benefit categories. 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 coinsurances for a practitioner service with 
ultrasound guidance and an injection on February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy, diagnostic, unilateral or bilateral 
(31231) and office or other outpatient visit for the evaluation and management of a new patient, which requires 
a medically appropriate history and/or examination and moderate level of medical decision making (99204) 
provided on December 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nasal endoscopy and office visit. You say that these necessary services 
should be covered. The Plan denied your request. The Plan says these services are not covered because they 
were provided OON 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 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 nasal endoscopy, diagnostic, unilateral or 
bilateral (31231) and office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making 
(99204) provided on December 1, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
January 25, 2022. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99153 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service).  
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional 
Component (PC)/Technical Component (TC) indicator of 3 per the 2022 National Physician Fee Schedule 
Relative Value File January Release. This means this code may not be paid if provided to hospital outpatients. 
The code was billed with place of service 22 (On-campus outpatient hospital). Based on this information, we 
decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient services provided November 1, 
2021 to November 30, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient services. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 outpatient hospital services.  
 
You have been asked to pay a 20% coinsurance for the outpatient services. 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 outpatient services provided November 1, 2021 to November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services. 
 
You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the SNF services are not supported in the medical record. Specifically, this claim requires a 
prospective payment system (PPS) code. The claim was not provided with this PPS code. This means the claim 
is not payable as billed. The Plan has attempted to receive this required information. Based on this information, 
we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that 
the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for outpatient surgery
services and neurostimulator implantation provided on August 20, 2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was applied based on the services provided and the
Plan contract agreement. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct contract language.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a $100 copayment for
outpatient surgery services and a 20% coinsurance for prosthetic devices. Devices (other than dental) that
replace all or part of a body part or function are a prosthetic device. For example, when you have a device such
as a pacemaker, colostomy bag, or in your case a neurostimulator implanted into the body to take the place of a
part of the body that no longer functions or requires assistance, such as pain for nerve damage, it is not
considered traditional durable medical equipment and it's considered a prosthetic device.
In addition, you are only being charged $86.72 (instead of $100) for this outpatient surgical event because you
met your maximum out of pocket for 2021. 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 or reduce the cost
share charged for outpatient hospital services and neurostimulator implantation provided on August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the computer assist is not needed. 
Medical literature has not shown any functional benefit of computer-assisted total knee surgery over open 
conventional surgery. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computer-assisted surgical navigational procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services can be received in-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 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 November 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for the dental services provided on August 11, 2021.
You asked the Plan to pay for these dental services. You say that if your dentist tells you that you need a
service you take that advice. The Plan denied your request. The Plan says the issue was not medical need but
the fact that the services provided were not covered under your Plan contract. Maximus overturned the Plans
denial for insufficient information. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage; therefore, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit more than Medicare coverage, the crown and related services provided were not covered under
your contracts dental benefit. Therefore, we decided that the Plan does not have to pay for a porcelain crown
and related dental services provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23, 24, 25, and 26. 
 
You asked the Plan to pre-approve the crowns. You say that crowns are needed to prevent further attrition and 
potential pulpal exposure, eliminate painful symptoms, and restore teeth to proper form and function. The Plan 
denied your request. The Plan says there is no clinical evidence to support medical necessity. 
 
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 the crowns 
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 the crowns. Our reviewer says that 
given the Policy limitations on crowns, there would be no necessity for crowns on the lower anterior teeth. Our 
physician reviewer found the provided x-rays and photos show clear wear patterns in the incisal edges of the 
lower anterior. There does not appear to be loss of structure from fracture or caries. Our reviewer found that in 
this instance there is a lack of damage due to either caries or trauma, though there is loss of structure from 
abrasion/attrition. Our physician reviewer also found that any wear seen on the teeth in question can be restored 
with composite materials, particularly as there is no natural tooth opposing them in the occlusion. 
 
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 the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #'s 23, 24, 25, and 26.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan must hold you harmless for the additional $42 worth of dental services provided on 
January 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the maintenance of gums and bones was 
not performed as described in the denial. You also say that the dental office performed preventative routine 
teeth cleaning, x-rays and fluoride treatments which are covered under your plan. The Plan denied your request. 
The Plan says that you were approved for reimbursement of $250.00. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the dental services by a contract provider. The file does not show that the Plan provided 
notice that the additional $42 worth of dental services would not be covered. Under Medicare rules, this means 
the additional $42 worth of dental services is considered approved by the Plan. Therefore, we decided that the 
Plan has to hold you harmless for the additional $42 worth of dental services provided on January 21, 2022.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $194.10 copayment charged for magnetic resonance
imaging (MRI) services provided on July 24, 2021.
You asked the Plan to waive this cost share. You say that you were told you were given an x-ray. The Plan
denied your request. The Plan says the medical records and claim billed by the provider clearly show an MRI
was provided. Maximus administratively overturned the Plans denial because a full copy of the Plans 2021
Evidence of Coverage was not included with the case file. The Plan requested a reopen and provided the
required Plan contract.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you pay a $300 copayment for outpatient
diagnostic imaging other than x-rays.
The medical records confirm that you had an MRI of the right lower extremity. In this case, you are being
asked to pay less than your normal copayment expectation of $300. 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 $194.10 copayment charged for magnetic resonance imaging (MRI) services provided on July 24, 2021.