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

 
We decided that the Plan does not have to pay for oral/facial photographic image obtained intra-orally or extra-
orally (code D0350), a comprehensive oral evaluation (code D0150), panoramic radiographic image (D0330) 
and intraoral - complete series (including Bitewings) (code D0210) provided from June 2, 2023, to 
July 20, 2023. 
 
You asked the Plan to pay for oral/facial photographic image obtained intra-orally or extra-orally, a 
comprehensive oral evaluation, a panoramic radiographic image and intraoral - complete series  (including Bitewings). You say that the services were medically necessary. The Plan denied your request. The 
Plan says oral/facial photographic image obtained intra-orally or extra-orally (code D0350) is not a covered 
benefit. The frequency has been exceeded for the comprehensive oral evaluation (code D0150), panoramic 
radiographic image (D0330) and intraoral - complete series (including Bitewings) (code D0210). 
 
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 requested oral/facial photographic 
image obtained intra-orally or extra-orally (code D0350) is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for oral/facial photographic image obtained intra-
orally or extra-orally (code D0350) provided from June 2, 2023, to July 20, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for panoramic radiographic image (D0330) and the comprehensive oral evaluation  
(code D0150) and intraoral - complete series (including Bitewings) (code D0210) was exhausted on  
December 13, 2022. Therefore, we decided that the Plan does not have to pay for panoramic radiographic 
image (D0330) and the comprehensive oral evaluation (code D0150) and intraoral - complete series (including 
Bitewings) (code D0210) provided from June 2, 2023, to July 20, 2023.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to provide coverage for skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF admission
was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not
met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply
the correct criteria. The Plan noted that the enrollees therapy notes show an ability to walk using an assistive
device. The notes show that at the time of the appeal the enrollee was at baseline level of function. The medical
records show at the time of the appeal the enrollee had no new medications, and no open wounds. The Plan
states the medical records did not show the enrollee required daily skilled therapy or daily skilled therapy
services at an inpatient level of care.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Based on the medical records provided, at the time of the appeal, the enrollees needs were custodial in nature,
and which is not covered by Medicare for SNF placement. Therefore, we decided that the Plan does not have to
provide coverage for skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a residence visit provided on June 23, 2023. 
 
You asked the Plan to pay for a residence visit. You say that you are appealing the denial. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 residence visit provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 25, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the laboratory services provided on July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
August 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 the urine polymerase chain reaction (PCR) 
panel rendered on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 18, 2023, to 
October 22, 2023. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the services are included in the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic services (including clinical diagnostic 
laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly 
operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission 
are deemed to be inpatient services and included in the inpatient payment. 
 
We looked at the file and Medicare rules. The records show that the claim in dispute was billed for dates of 
service starting on October 18, 2023, which is within 3 days of date of the date of admission. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on October 18, 
2023, to October 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 18, 2023, to 
February 16, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 18, 2023. The NOA was not received by the Plan until April 28, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 18, 2023, to February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
September 08, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you are being billed 
more than one 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 $35 
copayment for in-network physician/practitioner services, including a specialist visit. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including a specialist visit 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 specialist office visit provided on September 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee is under an active care plan. 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the laboratory services provided on June 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 13, 2023, to June 
28, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe you timely filed this NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 13, 2023. The NOA was not received by the Plan until September 6, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 13, 2023, to June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on September 22, 2023. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you are on a 
fixed income. 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for the myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the myocardial perfusion imaging provided on September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus and diphtheria immunization and the 
administration services provided on September 6, 2023. 
 
You asked the Plan to pay for the immunization and the administration services. You say that you were not told 
to go to the pharmacy for these services. The Plan denied your request. The Plan says these services are not 
covered under your Plan benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations 
and the administration services. The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the 
immunization and the administration services. Therefore, we decided that the Plan does not have to pay for the 
tetanus and diphtheria immunization and the administration services provided on September 6, 2023.  
 
Benefits for the immunization and the administration services may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 24, 2023, to March 26, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you want you 
classification to be changed back to inpatient and the bill resubmitted. 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 the emergency room services. 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 the emergency room 
services provided on March 24, 2023, to March 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on January 25, 2023, to February 
14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visits. You say that you say you received emergency eye care and there 
are no network providers within 20 miles of your rural location. 
 The Plan denied your request. The Plan says the provider was out-of-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 Plan had network providers available who were capable of providing the office visits. (Please note, items 
and services received in-network are still subject to any other Medicare coverage rules that apply.) The Plan 
did not pre-approve the office visits. 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 office visits provided on 
January 25, 2023, to February 14, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
October 17, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 the urine polymerase chain reaction (PCR) 
panel rendered on October 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies (A7035, A4604, A7031, A7033, A7046, 
A7032, A7030, A7036, A7038, A7039) for a continuous positive air pressure (CPAP) machine. 
 
You asked the Plan to pre-approve the CPAP supplies.. You say that these items are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that adherence to therapy is defined as use of CPAP 4 
hours or more per night on 70% of nights during a consecutive thirty (30) day period anytime during the first 
three (3) months of initial usage. 
 
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 CPAP supplies.. Our reviewer says 
that the requested supplies are not medically necessary. Our physician reviewer found the records do not show 
compliance as defined by the Medicare rules. Since continued coverage criteria for the CPAP are not met, the 
additional supplies are not 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 the CPAP supplies. have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies (A7035, A4604, A7031, A7033, A7046, A7032, A7030, A7036, A7038, 
A7039) for a continuous positive air pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis provided on 
August 22, 2023. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that you were told you 
would have $0 responsibility for this item. 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 prosthetic devices and related supplies, including orthotics. 
 
You have been asked to pay 20% coinsurance for the lumbar-sacral orthosis. This item/service falls within the 
in-network prosthetic devices and related supplies, including orthotics 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 $167.43 
($837.17 allowed amount x 20% = $167.43). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the lumbar-sacral orthosis provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 24, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told by three 
different people that you would not have a cost share for this visit. 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 $15 
copayment for in-network physician/practitioner services, including an in-person specialist visit. 
 
You have been asked to pay a $15 copayment for the specialist office visit. This item/service falls within the in-network physician/practitioner services, including an in-person specialist visit 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 specialist office visit provided on August 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 1, 2022, to July 
15, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder 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 the home health services. Our reviewer says that the records 
do not support the services billed. Our reviewer found the records do not show that a physical therapist 
performed the services. HIPPS code 3IC11 is not supported. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on July 1, 2022, to July 15, 2022.