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

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 21, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation, panoramic radiographic image, and an 
endosteal implant (D0140, D6010, D0330) provided on February 1, 2023 to, February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your $2,000 dental benefit maximum 
allowance for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a limited oral evaluation, panoramic radiographic 
image, and an endosteal implant (D0140, D6010, D0330) provided on February 1, 2023 to, February 8, 2023.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cardiac rehabilitation visit provided 
on January 02, 2023, to February 06, 2023. 
 
You asked the Plan to waive the copayment for each cardiac rehabilitation visit. You say that the benefits 
changed in the middle of treatment, and you were not expecting a copayment. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for in-network cardiac rehabilitation services. 
 
You have been asked to pay a $30 copayment for each cardiac rehabilitation visit. This item/service falls within 
the in-network cardiac rehabilitation 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. The total amount you owe is $510 ($30 copayment x 17 visits = $510). 
Therefore, we decided that the Plan does not have to waive the copayment for each cardiac rehabilitation visit 
provided on January 02, 2023, to February 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary and mandibular complete denture (D5110, 
D5120) provided on October 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
maxillary and mandibular complete denture (D5110, D5120) provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each skin debridement procedure provided 
on October 20, 2022, to November 20, 2022. 
 
You asked the Plan to reduce the copayment for each skin debridement procedure. You say that the two visits 
were considered specialist office visits. 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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $295 copayment for each skin debridement procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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. The medical records show 
the enrollee received a wound debridement procedure on both dates of service. The total amount you owe is 
$590 ($295 copayment x 2 visits = $590). Therefore, we decided that the Plan does not have to reduce the 
copayment for each skin debridement procedure provided on October 20, 2022, to November 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak and needs rehab after hospital 
discharge. The Plan denied your request. The Plan says that the enrollee does not meet all of the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the patient's documented nursing, medical, and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Clinical documentation shows that enrollee requires ongoing physical therapy and 
occupational therapy but does not show that the enrollee would require an intensive rehabilitation regimen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing, caries risk 
assessment and documentation, and gingival irrigation services (D0603, D4341, D4921) provided on 
November 30, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your $1,000 dental benefit maximum 
allowance 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 November 30, 2022. 
Therefore, we decided that the Plan does not have to pay more for periodontal scaling and root planing, caries 
risk assessment and documentation, and gingival irrigation services (D0603, D4341, D4921) provided on 
November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on 
January 24, 2023, to February 10, 2023. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that these supplies were 
ordered in error, you did not need many of them. 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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the wound care supplies. This item/service falls within the in-
network 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 coinsurance for the wound care supplies provided on January 24, 2023, to February 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the inpatient hospital stay provided on 
November 19, 2022, to November 20, 2022. 
 
You asked the Plan to reduce the coinsurance for the inpatient hospital stay. You say that you have not had to 
pay this amount for this service in the past. 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 in-network inpatient hospital care. 
 
You have been asked to pay 20% coinsurance for the inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital 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. The total you owe is $1,207.46 ($6,037.29 allowed amount  x 20% coinsurance 
= $1,207.46). Therefore, we decided that the Plan does not have to reduce the coinsurance for the inpatient 
hospital stay provided on November 19, 2022, to November 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
February 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency care visit. 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 a $125 
copayment for Emergency care. 
 
You have been asked to pay a $125 copayment for an emergency care visit. This item/service 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 an emergency care 
visit provided on February 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 25, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this should be paid in full, 
you could not find an in-network provider during an emergency. 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 $290 
copayment for out-of-network ambulance services. 
 
You have been asked to pay a $290 copayment for the ambulance services. This item/service falls within the 
out-of-network ambulance 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 copayment for 
the ambulance services provided on November 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit provided on 
August 16, 2022, and the specialist office visit provided on August 19, 2022. 
 
You asked the Plan to waive the copayments for the emergency room visit and the specialist office visit. You 
say that you should not have to pay for either service as they were related to an operation. 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 $120 
copayment for emergency services. Your contract with the Plan also clearly says that you must pay a $40 
copayment for specialist office visits. 
 
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $40 copayment for the specialist office 
visit. This item/service falls within the physician/practitioner services, including doctor's office visits benefit 
category. You have been asked to pay a total of $160 ($120 copayment + $40 copayment = $160). 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 emergency room visit provided on August 16, 2022, and the 
specialist office visit provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 99153 and 49441. provided on October 21, 2021.
You asked the Plan to pay for code 99153 and 49441. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen provided documentation to show codes 49440 and 99152 were paid. Procedure code 49441 was denied as it was part of the primary procedure code 49440 and ineligible for separate payment.
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 codes 49441 and 99153 could not be paid as billed due as they were not eligible for separate payment based on the related codes on the claim. Medicare billing criteria were not met.
Therefore, we decided that the Plan does not have to pay for surgical services provided on October 21, 2021 and billed under codes 99153 and 49441.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services (95938, 95957, 95861, G0453 and 95870) provided to the enrollee on September 8, 2022.
You asked the Plan to pay for code 95780. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided proof of payment for the overturned codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case code 95870 is a column II code to column I code 95861. This claim was not billed with an appropriate modifier to bypass the edit. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for code 95870, provided to the enrollee on September 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for fam-trastuzumab deruxtecan provided on October 19, 2022. 
 
You asked the Plan to pay for fam-trastuzumab deruxtecan. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says that 
charges for or in connection with services or supplies that are determined to be experimental or investigational 
are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 fam-trastuzumab deruxtecan. Our reviewer 
says that fam-trastuzumab deruxtecan is medically necessary. Our physician reviewer found that fam-
trastuzumab deruxtecan is FDA approved for the enrollees diagnosis. The documentation also supports that the 
requested drug is safe, effective, and reasonable and 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 fam-trastuzumab deruxtecan have been met. Therefore, we decided that the Plan 
has to pay for fam-trastuzumab deruxtecan provided on October 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided 
on February 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered by Medicare or the Plan. 
 
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, the procedure would not be covered under your medical 
benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge 
preservation provided on February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone density scan provided on January 18, 2023. 
 
You asked the Plan to pay for a bone density scan. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a bone density scan 
provided on January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services billed to the enrollee for September 17, 2022 to September 18, 2022 under code 99291.
You asked the Plan to pay this claim. 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 file about the previously paid claim. The Plan requested a reopen and provided the missing claim information. The records show code 99291 has an MUE value of 1, however 2 units were billed on two separate claims which is not allowed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim could not be paid as billed due to an error with MUE code value. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for hospital services billed to the enrollee for September 17, 2022, to September 18, 2022 under code 99291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the hospital clinic visit provided on August 
30, 2022. 
 
You asked the Plan to reduce the copayment for the hospital clinic visit. You say that you should only be 
responsible for a $25 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the hospital clinic visit. This item/service falls within the 
outpatient hospital 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. However, since the allowed amount is less than the standard copayment, you only owe 
$117.53. Therefore, we decided that the Plan does not have to reduce the copayment for the hospital clinic visit 
provided on August 30, 2022.