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

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on March 2, 
2023, to May 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 dental services provided by an OON provider on March 2, 2023, to May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy and sedation provided on 
September 18, 2023. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy and sedation. You say that this procedure was 
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 esophagogastroduodenoscopy and sedation provided on September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 9, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting a review of the claim 
for payment. The Plan denied your request. The Plan says enrollees must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the subsequent nursing facility care (99309) provided on June 9, 2023, 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 established patient home or residence visit (99348) 
provided on August 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home or residence visit. You say that please review and reprocess the claim. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the established patient home or residence visit (99348) provided on August 25, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back and knee orthoses billed for date of service August 
15, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no order for the items at issue and the medical records 
do not support the orthoses as part of treatment for a specific medical problem. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the back and knee orthoses billed for date of service August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the removal of earwax services provided 
on September 11, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and the removal of earwax services. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the services were not authorized.   
 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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the office visit and the removal of earwax services provided on September 11, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a home ventilator for the enrollee.

You asked the Plan to provide coverage for a home ventilator. You say that this device is medically necessary.
The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that ventilators may be
covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive
diseases, and chronic respiratory failure due to COPD. Claims for ventilators used to provide CPAP or bi-level
CPAP therapy will be denied as not reasonable and necessary. Approval of 3 months for transition does not
meet coverage criteria based on how the ventilator is used. The medical records show the enrollee has COPD
and severe obesity and has been using a home ventilator since 2021. A compliance download covering May 10
to June 8, 2023, showed only 47% of days use with at least 4 hours of usage. Previously, April 17 to May 16,
usage was 90%. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee's
respiratory support needs could be met with BiPAP with AVAPS. Medicare does not cover a home ventilator
when used at settings that can be provided with BiPAP. Medicare rules for coverage of a home ventilator have
not been met. Therefore, we decided that the Plan does not have to provide coverage for a home ventilator for
the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on July 20, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0012M) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the office visits, the debridement 
procedures, and the x-ray provided from August 1, 2023, to August 23, 2023. 
 
You asked the Plan to reduce the deductible for the office visits, the debridement procedures, and the x-ray. 
You say that you were unaware the provider was out-of-network. 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. Your 
contract with the Plan says that there is a $1,300 deductible which applies to physician/practitioner services, 
including doctor's office visits.  You have been asked to pay $166.63 towards your deductible for the specialist office visit provided on August 
1, 2023. You have also been asked to pay $127.05 towards your deductible for the specialist office visit 
provided on August 9, 2023. You have also been asked to pay $127.09 towards your deductible for each 
debridement procedure provided on August 1, 2023, August 9, 2023, and August 16, 2023. You have also been 
asked to pay $98.49 towards your deductible for the debridement procedure provided on August 23, 2023. The 
items or services you asked the Plan to reduce the deductible for fall within the physician/practitioner services, 
including doctor's office visits benefit category. You have also been asked to pay $33.50 towards your 
deductible for the x-ray provided on August 1, 2023. The item or service you asked the Plan to reduce the 
deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category.  
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,300 deductible 
which applies to physician/practitioner services, including doctor's office visits and outpatient diagnostic tests 
and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the 
time the office visits, the debridement procedures, and the x-ray was received on August 1, 2023, to August 23, 
2023. Therefore, we decided that the Plan does not have to reduce the deductible for the office visits, the 
debridement procedures, and the x-ray provided from August 1, 2023, to August 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF 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 medical records show this enrollee's ability to participate in intensive
therapy was limited by the new below the knee right leg amputation, as well as his weakness and fatigue.
The therapists commented on worsened pain and fatigue due to "overuse" in the therapy sessions at the
hospital.

The enrollee's amputation stump was still healing and not ready for prosthesis training yet.

The Plan is correct in this case. 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. The
medical records provided do not show the enrollee had the ability to participate in the type of intensive therapy
program provided at an IRF. 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 provide coverage for acute
inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 18, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
You also say to please review the appeal letter and process the claim. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and is not enrolled in Medicare as a durable medical equipment 
supplier. 
 
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 the supply allowance for a continuous 
glucose monitor (CGM) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on July 27, 2023. 
 
You asked the Plan to waive the coinsurance for the Part B drug. You say that you think the amount your 
responsible for may be incorrect. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Part B drug. This item/service falls within the Medicare 
Part B prescription drugs 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, the total amount you owe is $85.08, which is less than 20% coinsurance of the 
allowed amount. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B 
drug provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient home or residence services (99349, 
99348) provided on August 28, 2023, to September 4, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home visit services. You say that you would like to appeal for retroactive 
authorization based on medical necessity. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the established patient home or residence services (99349, 99348) provided on August 28, 2023, to September 
4, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 27, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
You also say to please review the appeal letter and process the claim. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and is not enrolled in Medicare as a durable medical equipment 
supplier. 
 
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 the supply allowance for a continuous 
glucose monitor (CGM) provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on January 
12, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that this testing is medically necessary.  
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for biomarker testing to be covered the 
biomarkers must have proven clinical validity/utility. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on 
January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 03, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. 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 chiropractic services provided on July 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile foam dressing (A6213) and sterile alginate or 
other fiber gelling dressing (A6196) provided on May 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that you request reconsideration of this claim 
for payment based on the medical necessity of the surgical dressings. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the sterile foam dressing (A6213) and sterile alginate or other fiber gelling dressing (A6196) provided on May 
15, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 18, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies 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 wound care supplies provided on September 18, 2023.