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

 
We decided that the Plan does not have to pay for the wound care services provided on May 11, 2023, by an 
out-of-network provider. 
 
You asked the Plan to pay for the wound care services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says wound care services are available with in-network 
providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the wound care services provided on May 11, 2023, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided to the enrollee on December 19, 2022.

You asked the Plan to pay for the testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says the provider did not bill with one of the recommended procedure codes for Z-code ZB1CW. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 

We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the  testing provided to the enrollee on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on May 02, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you feel the cost share applied 
should be covered because the amount was never discussed. 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 an injection. 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. The total coinsurance you owe is $415.80, which is 20% of the allowed amount for a Medicare Part 
B non-chemotherapy drug injection ($2,079 allowed x 20% = $415.80). Therefore, we decided that the Plan 
does not have to waive the coinsurance for an injection provided on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were visiting Los Angeles and you had 
tooth pain that needed immediate attention. 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 on June 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that Ozempic is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.   
Benefits for the medication 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue (D4381) provided on July 24, 2023. 
 
You asked the Plan to pay for localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue (D4381). You say that this was already approved prior to the procedure. The Plan 
denied your request. The Plan says that localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue (D4381) is not allowed on the same date of service as root planing and 
scaling (D4341). 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue (D4381) by a contract provider. The file does not show that the Plan provided notice that 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue 
(D4381) would not be covered. Specifically, the Plans dental policy actually does not explicitly state that 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue 
(D4381) cannot be billed with any other code. There is not a clear or explicit billing exclusion that the enrollee 
would have been able to know about. Under Medicare rules, this means localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue (D4381) is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue (D4381) provided on July 24, 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 pre-approve physical therapy visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee lives alone, and this is 
closer to the enrollees. home. The Plan denied your request. The Plan says OON providers are not a covered 
benefit. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says at the time of service you were not an eligible provider. Maximus overturned the Plan's decision for insufficient information in the case file. The Plan requested a reopen and provided documentation to show that as of April 20, 2022, the providing physician was in an exclusion status for Medicare claims.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

However, there is no record of a private contract between the provider and the enrollee to accept services by the rendering physician.

Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 21, 2022, and billed under code 77080.

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 the Medicare billing criteria were not met.

Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that this claim denied because this service was billed with an inappropriate Diagnosis Code. The claim was billed with diagnosis code Z13.820 or encounter for screening for osteoporosis which is not considered as appropriate diagnosis code for Dual energy X-ray absorptiometry (DXA) as per the Medicare guidelines. The medical records do not show the enrollee received the screening study for one of the risk categories listed in Medicare guidelines.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Diagnostics must be reported with the appropriate diagnosis code. In this case, the diagnosis code reported is not one showing to be covered by Medicare for this type of scan. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 21, 2022, and billed under code 77080.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care office visit provided on 
April 26, 2023. 
 
You asked the Plan to waive the copayment for the urgent care office visit. You say that you did not see this 
provider on this date. 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 urgently needed services. 
 
You have been asked to pay a $30 copayment for the urgent care office visit. This item/service falls within the 
urgently needed 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 medical records show you were seen by this provider on April 26, 2023. Therefore, 
we decided that the Plan does not have to waive the copayment for the urgent care office visit provided on 
April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like to continue to see your provider. 
The Plan denied your request. The Plan says this is available in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI and outpatient hospital visits on 
February 06, 2023, to May 25, 2023.  
 
You asked the Plan to waive the copayment for an MRI and outpatient hospital visits. You say that you don't 
understand why you are being charged these amounts. 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 $275 
copayment per day, per provider, for Medicare-covered diagnostic radiology services. You must a $325 
copayment for each Medicare-covered outpatient hospital facility visit. There were two outpatient hospital 
visits (2 x $325 = $650). Therefore, the total you owe is $925 ($275 copayment + $650 copayments = $925).  
 
You have been asked to pay a $275 copayment for an MRI and a $325 copayment for each outpatient hospital 
visit. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and 
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. Therefore, we decided that the Plan does not have to waive the copayment for an MRI and 
outpatient hospital visits on February 06, 2023, to May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on June 1, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that you have been with this provider for an 
extended period of time. You also say that at this point of your life, starting all over with a new provider is not 
something you are comfortable with. The Plan denied your request. The Plan says hearing aids must be 
purchased through a Plan hearing network provider to be covered under the hearing aid services offered by the 
Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are purchased through a Plan hearing network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on June 1, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 10, 2023. 
 
You asked the Plan to pay for the laboratory 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 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 the laboratory services 
provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tracker. 
 
You asked the Plan to pre-approve a tracker. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tracker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance transportation provided on 
April 20, 2023. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that the amount being 
charged is too high. 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 ambulance services. 
 
You have been asked to pay a $350 copayment for the ambulance transportation. This item/service falls within 
the 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 reduce the copayment for the 
ambulance transportation provided on April 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on June 
9, 2023. 
 
You asked the Plan to pay for non-covered ambulance mileage (A0888). You say that you called an ambulance 
for an issue after surgery. You also say that you requested to be taken to the facility that did the surgery. The 
Plan denied your request. The Plan says your coverage does not provider for this ambulance service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record shows that you requested to be taken to a facility that was 
not the closest facility, but the facility where you had your surgery. Based on this information, we decided that 
Medicare rules for coverage of non-covered ambulance mileage (A0888) have not been met. Therefore, we 
decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on June 9, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure and complete 
maxillary/mandibular dentures (D1999, D5110, D5120) provided on May 26, 2023, to June 2, 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 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 an 
unspecified preventive procedure and complete maxillary/mandibular dentures (D1999, D5110, D5120) 
provided on May 26, 2023, to June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on February 03, 
2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were advised your copayment 
would only be $35. 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 an injection. 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. The total coinsurance you owe is $187.97, which is 20% of the allowed amount for a Medicare Part 
B drug injection ($939.84 allowed x 20% = $187.97). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an injection provided on February 03, 2023.