Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network left hip x-ray and 
appointment provided on June 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network left hip x-ray and appointment. You say that this 
was an x-ray and office visit before a surgery and should not have a copay. 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 $50 
copayment for Outpatient Diagnostic Tests and Therapeutic Servicesand Supplies, and Physician/Practitioner 
Services, Including Doctors Office Visits.  
You have been asked to pay a $50 copayment for an in-network left hip x-ray and appointment. This 
item/service falls within the Outpatient Diagnostic Tests and Therapeutic Servicesand Supplies, and 
Physician/Practitioner Services, Including Doctors Office Visits 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. $15 office visit copayment + $35 x-ray copayment 
= $50 total. Therefore, we decided that the Plan does not have to waive the copayment for an in-network left 
hip x-ray and appointment provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on March 07, 2023, to 
May 02, 2023. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were never informed of the cost 
share that would be charged for the injections. 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 injections. 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. You have been asked to pay $1,638.61, which is 20% of the allowed amount for Medicare Part B 
drug injections performed from March 7, 2023, to May 2, 2023. Therefore, we decided that the Plan does not 
have to waive the coinsurance for injections provided on March 07, 2023, to May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 27, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered 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 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 home visit provided on 
July 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 27, 2023, to May 26, 2023. 
 
You asked the Plan to pay for SNF care. You say that the enrollee required SNF services. The Plan denied your 
request. The Plan says the enrollee did not require SNF services. 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. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 27, 2023, to May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on June 23, 2023.  
 
You asked the Plan to waive the deductible for an office visit. You say that the copayment should be $45 for 
in-network doctors. 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 $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on June 23, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on July 26, 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 a 
comprehensive periodontal evaluation (D0180) provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on February 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of 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 service 
provided on February 20, 2023.
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 needs physical therapy and occupational 
therapy, as well as wound care. The Plan denied your request. The Plan says the enrollee's condition does not 
meet Medicare guidelines.  
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture and non-operative management of a radial fracture after a fall. 
The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each defibrillator garment rental provided 
on June 09, 2023, to July 09, 2023. 
 
You asked the Plan to reduce the coinsurance for each defibrillator garment rental. You say that you cannot 
afford the cost share. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each defibrillator garment rental. This item/service falls 
within the 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 reduce the coinsurance for each defibrillator garment rental provided on June 09, 2023, to July 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images, intraoral x-rays, pulp vitality 
tests, and topical application of fluoride varnish (D1206, D0460, D0330, D0210) provided on July 7, 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 your benefit for the requested item or service has 
already been exhausted. Additionally, this benefit does not include pulp vitality tests or topical application of 
fluoride varnish. 
 
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 July 7, 2023. 
Additionally, this benefit does not include pulp vitality tests or topical application of fluoride varnish. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic images, intraoral x-rays, 
pulp vitality tests, and topical application of fluoride varnish (D1206, D0460, D0330, D0210) provided on July 
7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 
24, 2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with 
having to pay 5 days and that it should be 2 day 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 $175 
copayment for inpatient hospital care.  
You have been asked to pay a $175 copayment for the inpatient hospital stay. This item/service falls within the 
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. You have been asked to pay a total of $875 for the inpatient hospital stay ($175 copayment 
x 5 days = $875). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on June 24, 2023, to June 
29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a bevacizumab injection and a specialist 
office visit provided on August 14, 2023. 
 
You asked the Plan to reduce the cost share for an injection and a specialist office visit. You say that you 
believed that the Plan would pay more for these services. 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. Your contract with the Plan also clearly says that you must 
pay a $45 copayment for each in-person specialist visit. 
 
You have been asked to pay $14.72, which is 20% coinsurance of the allowed amount for an injection ($73.58 
allowed amount x 20% = $14.72). 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.  
 
You have also been asked to pay a $45 copayment for the specialist office visit. This item/service falls within 
the physician/practitioner services, including doctor's office visits benefit category. The total amount you owe 
is $59.72 ($14.72 coinsurance + $45 copayment = $59.72). 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 cost share 
for a bevacizumab injection and a specialist office visit provided on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out of network micropayment provided 
on March 28, 2023. 
 
You asked the Plan to waive the copayment for an out of network micropayment. You say that you paid for this 
item out of pocket and want it reimbursed. 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 
$149.99 copayment for durable medical equipment and related equipment.. 
 
You have been asked to pay a $149.99 copayment for an out of network micropayment. This item/service falls 
within the durable medical equipment and related equipment. 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 out of network micropayment provided on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network total ankle replacement 
surgery. provided on April 11, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network total ankle replacement surgery.. You say that 
you need to have this done but cannot afford this copay. 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 surgical procedures and other outpatient services. 
 
You have been asked to pay 20% coinsurance for an in-network total ankle replacement surgery.. This item/service falls within the surgical procedures and other outpatient 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 you you owe is $2244 
Therefore, we decided that the Plan does not have to waive the coinsurance for an in-network total ankle 
replacement surgery. provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for power wheelchair accessories for the enrollee
coded as E2311, E2313, E2377 and K0108.

You asked the Plan to provide coverage for these accessories. You say that at the time of the appeal these
accessories were medically necessary. The Plan denied your request. The Plan says these accessories are not
shown to be medically necessary. Maximus overturned the Plans denial. The Plan requested a reopen and stated
that the Maximus decision was inconsistent with the enrollee's medical needs. The Plan noted the medical
records do not show a medical need to control these power options through the joystick, The records show the
enrollee has adequate strength in the right upper extremity to operate the power wheelchair. The enrollee is
independent with feeding. The records show the enrollee's upper limb functionality will enable the enrollee to
control the power options using their own switches which are included in the allowance of these power
options. The K0108 switch is already included with the requested E2377 Expandable Controller and cannot be
requested separately. Therefore, codes E2311, E2313, E2377 and K0108 were denied appropriately.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. Based on the medical records provided, the requested
accessories were either billed inappropriately or exceed the enrollee's equipment need.

Therefore, we decided that the Plan does not have to provide coverage for power wheelchair accessories for the
enrollee coded as E2311, E2313, E2377 and K0108.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 
87563, 87640, 87653, and 87798 for date of service June 8, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87481, 87491, 87563, 87640, 87653, 
and 87798. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 87563, 87640, 87653, and 
87798 for date of service June 8, 2023.