Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a specialist office visit on June 27, 2022. 
 
You asked the Plan to reduce the copayment for a specialist visit. You say that you should only be responsible 
to pay a $40 copayment. The Plan denied your request. The Plan says that the cost share has been applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $40 copayment each in-network specialists office visit.  
 
The Plan says you must pay a $100 copayment for a specialist visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $40 copayment for a specialist visit. Therefore, we decided that the Plan 
has to reduce the copayment for a specialist office visit on June 27, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 21, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you did bill the primary insurance, so the Plan 
should reprocess this claim accordingly. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the enrollee's primary insurance carrier already paid more than the Medicare 
allowed amount for this claim so no further payment can be made. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurance carrier has already processed this claim and paid more than the Medicare allowable 
amount. Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120) and a 
periapical x-ray (D0220) provided on March 23, 2022. 
 
You asked the Plan to waive the coinsurance for an evaluation and x-ray. You say that you get anxiety seeing 
other dentists. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 50% coinsurance for of billed charges up to the $2,750 allowance for all covered dental services when received by 
an out-of-network provider.  
 
You have been asked to pay $30, which is 50% coinsurance of the allowed amount for an evaluation ($60 
allowed amount x 50% coinsurance = $30). You have also been asked to pay $16, which is 50% coinsurance of 
the allowed amount for an x-ray ($32 allowed amount x 50% coinsurance = $16). An evaluation and x-ray fall 
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 waive the coinsurance for a periodic 
oral evaluation (D0120) and a periapical x-ray (D0220) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342 and D4341) 
provided by a participating provider. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 
periodontal scaling and root planing (D4342 and D4341) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 
23, 2021, to September 25, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the admission and care are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee had an uncomplicated, non-
severe presentation. Therefore, the reviewer found that the documentation does not indicate that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 23, 2021, to September 
25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing panel provided on April 
13, 2022. 
 You asked the Plan to pay for the GeneSight Psychotropic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing has not been 
shown to be useful, is not considered medically necessary and appropriate, and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Therefore, we 
decided that the Plan does not have to pay for the GeneSight Psychotropic testing panel provided on April 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99212 x 4), duplex scans (93971 x 4), 
needle insertion (76942 x 4), injection of sclerosant (36471 x 3), and ablation therapy (36478) to be performed 
by an out-of-network provider. 
 You asked the Plan to pre-approve the physician services. You say that the requested services are intended to 
treat a serious medical condition. You also say that the services are medically necessary. The Plan denied your 
request. The Plan says the requested services can be provided in network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 physician services. Our reviewer 
says that it is not medically necessary for the requested services to be provided out-of-network. Our physician 
reviewer found the provided documentation does not show that the enrollee is currently in active treatment with 
the requested provider. The reviewer found that the documentation does not indicate anything unique about this 
enrollees condition that would make it medically necessary for her to continue care with the provider. The 
reviewer found that there are in-network providers available with the qualifications necessary. Therefore, the 
reviewer found that the requested services can safely be provided by an in-network radiology specialist. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve office visits (99212 x 4), duplex scans (93971 x 4), needle insertion (76942 x 4), 
injection of sclerosant (36471 x 3), and ablation therapy (36478) to be performed by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), an 
extraction of tooth #14 (D7210), bone replacement graft on tooth #14 (D7953), and guided tissue regeneration 
on tooth #14 (D4266) provided on May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and 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. 
 
The record shows you received the requested 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 pay for a comprehensive periodontal evaluation (D0180), an extraction of tooth #14 (D7210), bone 
replacement graft on tooth #14 (D7953), and guided tissue regeneration on tooth #14 (D4266) provided on May 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), bitewings 
(D0274), prophylaxis (D1110), and intraoral imaging (D0220), provided by an out-of-network provider on July 
12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like the Plan should be paying for 
more. 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 a comprehensive oral evaluation (D0150), 
bitewings (D0274), prophylaxis (D1110), and intraoral imaging (D0220), provided by an out-of-network 
provider on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft (D6104), surgical placement of transosteal 
implant (D6050), a custom fabricated abutment (D6057), and an abutment supported crown (D6058) received 
on November 16, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary, and your in-
network provider doesn't offer these services. The Plan denied your request. The Plan says the services at issue 
are not covered benefits. Additionally, services were rendered by 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. 
 
   
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. Additionally, services performed by an out-of-network provider are 
not covered. Therefore, we decided that the Plan does not have to pay for a bone graft (D6104), surgical 
placement of transosteal implant (D6050), a custom fabricated abutment (D6057), and an abutment supported 
crown (D6058) received on November 16, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem-focused re-evaluation of an existing condition 
(D0170) provided on April 14, 2022. 
 
You asked the Plan to pay for the problem-focused re-evaluation of an existing condition. You say that you 
contacted the Plan in March to help you find an in-network dentist. You say you were told that the closest 
provider was 130 miles away, but an exception could be made to see a provider closer to you. The Plan denied 
your request. The Plan says the claim was processed correctly. The requested service is not a covered benefit. 
 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 a 
problem-focused re-evaluation of an existing condition (D0170) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), prophylaxis (D1110), and resin-based composite (D2331) provided on February 
23, 2022, and March 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not advised that that these services 
would not be covered. The Plan denied your request. The Plan says the dental services were received from an 
OON provider and are not covered by your supplemental benefits. The Plan also says you did not contact the 
Plan prior to obtaining services to confirm the network status of the treating 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. 
 
 The record shows you received the requested dental services from an OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), prophylaxis (D1110), and 
resin-based composite (D2331) provided on February 23, 2022, and March 10, 2022, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued acute inpatient mental health admission. 
 
You asked the Plan to pre-approve a continued acute inpatient mental health admission. You say that you 
would like a continued stay to be authorized for the enrollee until they are stabilized. The Plan denied your 
request. The Plan says the requested service is not medically necessary as the submitted clinical information 
does not meet the Plan's criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 
 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 a continued acute inpatient mental 
health admission. Our reviewer says that the enrollee does not meet the Medicare criteria for a continued acute 
inpatient mental health admission. Our physician reviewer found it is not expected this enrollee would improve 
in a reasonable period of time as they do not have dangerousness to self or others, auditory or visual 
hallucinations, delusions and are not showing any behavioral issues. It is noted that the enrollee has been 
cooperative and compliant with treatment while not showing any aggressive behaviors. Our reviewer also 
found that it does not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued acute inpatient mental health admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continued acute inpatient mental health 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an endoskeletal knee-shin system and stance flexion feature.
You asked the Plan to provide coverage for an endoskeleton knee-shin system and stance flexion feature. You say that the requested prosthetic leg and components are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Maximus did not follow the required Medicare criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare will only approve an endoskeletal knee-shin system and stance flexion feature for a certain level of ambulation ability. The Maximus reviewer stated you would benefit from this accessory. While this may be true, Medicare requires that you meet all the required criteria at the time of the request for coverage. The medical records show at the time of your request you were using a walker for ambulation. This type of prosthetic accessory is only approved for enrollees who could traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. The medical record documentation does not show you met the required criteria for this accessory. We also find no specific records from your physician indicating the need for this accessory. Medicare coverage criteria were not met at the time of the required. Therefore, we decided that the Plan does not have to provide coverage for an endoskeletal knee-shin system and stance flexion feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
November 18, 2021. 
 
You asked the Plan to pay for a crown. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 a crown 
(D2740) provided by a participating provider on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 11, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (0037U) provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for genetic testing provided to the enrollee on November 5, 2021.
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 Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not follow the LCD criteria. The Plan demonstrated that
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, Medicare L35025 is applicable as the lab service was rendered in the
Provider's facility. The LCD states all tests billed within this jurisdiction are required to be
billed with a Unique Test Identifier. The claim submitted does not show a Unique Test Identifier issued by
MoIDX is billed on the claim. 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 pay for genetic testing
provided to the enrollee on November 5, 2021.