Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pay for the bitewing x-rays and comprehensive oral
evaluation provided on December 1, 2020.
You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says these services were not covered at the time of service. Maximus
partially overturned the Plans denial. The Plan requested a reopen and provided a rebuttal and additional
information. The Plan says it has been determined that code D0150 for comprehensive oral evaluation denied
because the frequency limitation had been exceeded for this service. The claim records show this benefit was
previously paid for on November 16, 2019. D. The Plan provided the Explanation of Remittance for the
previous claim showing payment. The Plan says that the Evidence of Coverage explains, a comprehensive oral
evaluation is allowed as one procedure every three years. Therefore, the service provided December 1, 2020
was not yet eligible for coverage as it was only one year since the previous evaluation.
The Plan is correct in the case. 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, services provided were not eligible for
coverage at the time of service. Therefore, we decided that the Plan does not have to pay for pay for the
bitewing x-rays and comprehensive oral evaluation provided on December 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380)
provided on April 21, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you have this colonoscopy every
year due to stomach issues and have never been charged a copay before. The Plan denied your request. The
Plan says this claim was processed correctly, and your copayment was assessed in accordance with your
contract.
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 $200
copayment for outpatient surgery services received at an ambulatory surgical center.
You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy billed with code 45380 is
classified as a surgical procedure and was provided at an ambulatory surgical center. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the colonoscopy with biopsy (45380) provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on May 21, 2021. 
 
You asked the Plan to pay for a seat lift mechanism. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
provider of the item at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided 
on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and amalgam (D2150) provided from March 30, 2021, to April 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and amalgam. You say that when you 
signed up with this plan you were told that your dental work would be covered in full up to to $1,500.00. The 
Plan denied your request. The Plan says the total amount of $136 applied correctly as your liability. The Plan 
also says that cost sharing is a contractual obligation under the Plan and cannot be waived. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference 
between the billed amount and allowed amount for covered dental services received OON. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and 
amalgam (D2150) provided from March 30, 2021, to April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 12, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 12,2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 8, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were misdiagnosed and were 
later admitted to the hospital so should not be responsible for the charges. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for emergency care.  
 
The medical records show that you received emergency care on November 8, 2020. Therefore, you are 
responsible to pay the $75 copayment.  
 
You have been asked to pay a $75 copayment for emergency care. Emergency care 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 care provided on 
November 8, 2020.  
 
We note your complaint that you were misdiagnosed. Your complaint is a grievance that must be answered by 
the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric upper extremity orthosis (L8702).
You asked the Plan to pre-approve the myoelectric upper extremity orthosis. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is experimental and non-covered.
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 the myoelectric upper extremity orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation to be investigational in nature with no long term outcome data at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the myoelectric upper extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric upper extremity orthosis (L8702).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation 
services (A0428, A0425) provided on February 9, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be liable 
for this bill and would not have accepted this transport if you knew the cost. The Plan denied your request. The 
Plan says this claim was processed correctly. Your contract states that you are responsible for a $200 
copayment for ambulance services. 
 
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 $200 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance 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 copayment for the non-emergent ambulance transportation services (A0428, A0425) provided on 
February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic or therapeutic agent injections. 
 
You asked the Plan to pre-approve diagnostic or therapeutic agent injections. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary when specific criteria are met. 
 
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 diagnostic or therapeutic agent 
injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has had low back pain with radiation to both legs for approximately one year. 
The record does not indicate that the enrollee has failed conservative care such as nonsteroidal anti-
inflammatory drugs (NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks. The record does 
not indicate that the pain is intermittent or continuous with average pain levels of 6 or greater on a visual-
numerical analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability. The elements 
of the coverage criteria are not satisfied. The requested service is not recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic or therapeutic agent injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve diagnostic or therapeutic agent injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three extractions, preventive procedure, and two 
alveoloplasties in conjunction with extractions, and to pay more for the extraction of tooth #10 provided on 
May 20, 2021. 
 
You asked the Plan to pay for the extractions, preventive procedure, and alveoloplasties, or pay more for the 
extraction of tooth #10. You say that you are on social security and do not have extra money to pay for these 
services. The Plan denied your request. The Plan says you have reached the annual dental maximum. The Plan 
also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers an annual maximum 
benefit of $2,000 per calendar year. The record shows that you met the annual maximum benefit while 
processing this claim for the May 20, 2021 date of service and your annual maximum benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the three extractions, preventive 
procedure, and two alveoloplasties in conjunction with extractions, and to pay more for the extraction of tooth 
#10 provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 12, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you saw your primary care physician and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $15 copayment for specialist services. The record shows that you had an office visit at a specialty office on August 12, 2021. Therefore, the services were rendered by a specialist and you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic radiology simulation-aided field setting 
(77280), radiation treatment therapy (77401), and the ultrasonic guidance for placement of radiation therapy 
fields (G6001) rendered by the out-of-network (OON) provider on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the therapeutic radiology simulation-aided field setting (77280), radiation 
treatment therapy (77401), and the ultrasonic guidance for placement of radiation therapy fields (G6001) 
rendered by the out-of-network (OON) provider on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), a resin-based composite - three surfaces (D2332), a resin-based composite - four surfaces (D2394) and a resin-based composite - three surfaces, posterior (D2393) provided on June 16, 2021, to July 7, 2021.
You asked the Plan to pay for dental services. You say that you did not see anything under dental that would indicate you needed dental insurance, so you were surprised when you received the notice of denial. The Plan denied your request. The Plan says there are no routine dental benefits with the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare and are not covered under your routine dental coverage. The records show that you were not enrolled with a dental plan on the date of service. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), a resin-based composite - three surfaces (D2332), a resin-based composite - four surfaces (D2394) and a resin-based composite - three surfaces, posterior (D2393) provided on June 16, 2021, to July 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (93798, G0128, 97110, G0239, 94761) 
provided March 29, 2021 to April 28, 2021. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the procedure codes billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the services billed with the -59 modifier were a distinct 
procedural service. Code 93798-59 was billed to the health plan with diagnosis codes Z96.659, I48.91 and 
R63.4. These Diagnosis codes are not the appropriate diagnosis codes to submit in order for 93798 to be 
considered for payment. The medical records provided do not include sufficient documentation to validate that 
G0128, 97110, and G0239 were performed as a distinct, separate service. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for therapy services (93798, G0128, 97110, G0239, 94761) 
provided March 29, 2021 to April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (80307) rendered by the out-of-network (OON) 
provider on March 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (80307) rendered by the out-of-network (OON) provider on March 18, 
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the positron emission tomography (PET) 
scan, the computed tomography (CT) scan of the chest, and CT scan of the abdomen you had on January 14, 
2020, the CT scans of the chest and abdomen you had on May 14, 2020, and the CT scans of the chest and 
abdomen you had on August 13, 2020. 
 
You asked the Plan to waive the copayments for the PET scan and the CT scans. You say that you believe this 
copayments were charged incorrectly. The Plan denied your request. The Plan says you were charged these 
copayments 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 $150 
copayment for diagnostic radiological services.  
 
You have been asked to pay a $150 copayment for each date of service for the PET scan and the CT scans. The 
PET scan and the CT scans fall within the diagnostic radiological 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 copayments for the positron emission tomography (PET) scan, the computed 
tomography (CT) scan of the chest, and CT scan of the abdomen you had on January 14, 2020, the CT scans of 
the chest and abdomen you had on May 14, 2020, and the CT scans of the chest and abdomen you had on 
August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide provided on January 27, 2021. 
 
You asked the Plan to pay for a stair glide. You say that the item at issue is a medical necessity for you. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature. 
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide provided on January 27, 2021.