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

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided to the 
enrollee on May 12, 2020. 
 
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare denies coverage for all cardiovascular risk assessment panels. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no clinical notes provided. The requisition lists unspecified abdominal pain and hypertension 
and hyperlipidemia. There is no information if this is an anginal equivalent or that the test will change 
management of risk factors or any symptoms. The Corus CAD cardiac risk assessment test has limited clinical 
data for its use at present. There is no compelling published data that it improves health outcomes at present 
and it will not definitively rule out the presence of CAD if the patient is indeed having compelling symptoms. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the cardiovascular risk assessment panel provided to the enrollee on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT image capture (D0380) provided on 
August 17, 2020. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that you were under the impression 
that this consult would be free. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT image capture (D0380) provided on August 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you believe that provided payment for this 
service is imperative to allow for continued service to all patients. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography studies (EMG) with CPT code 51785 
provided. 
 
You asked the Plan to pay for CPT code 51785. You say that the medical records support the billing of CPT 
code 51785. The Plan denied your request. The Plan says that the medical records do not support the billing of 
CPT code 51785. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 51785 is Needle electromyography studies (EMG) of anal or urethral sphincter, any technique. 
 
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 CPT code 51785. Our reviewer says that the 
medical records support the billing of CPT code 51785. Our physician reviewer found the intraoperative 
monitoring report indicates that spontaneous EMG recording was performed at the iliopsoas, quadriceps and 
anal sphincter. 
 
With regards to the NCCI on this code, the only mention of it is on page VII-8 where it says: 
 
"CPT codes 51784 and 51785 describe diagnostic electromyography (EMG). When EMG is performed as part 
of a biofeedback session, neither CPT code 51784 nor 51785 shall be reported unless a significant, separately 
identifiable diagnostic EMG service is provided. If either CPT code 51784 or CPT code 51785 is reported for a 
diagnostic electromyogram, a separate report must be available in the medical record to indicate this service 
was performed for diagnostic purposes". 
 
It can be inferred that the IONM report reflects that the EMG was done for diagnostic purposes. In this setting 
it appears the service was coded correctly in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 51785 have been met. Therefore, we decided that the Plan has to pay 
for the needle electromyography studies (EMG) with CPT code 51785 provided.  
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management and x-rays provided. 
 
You asked the Plan to pay for the services provided by a chiropractor. You say that you have used chiropractic 
care for many years and never have had service bills denied. The Plan denied your request. The Plan says they 
only cover manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the evaluation and management and x-rays provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive evaluation (D0150) and the bitewing x-
rays (D0274) provided on August 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan to ask if you were due 
for a routine cleaning. You say that the plan representative advised that cleanings were covered but did not 
mention anything about exceeding the frequency maximum. The Plan denied your request. The Plan says 1 
comprehensive evaluation is covered every 3 plan years. The Plan says that 1 set of bitewing x-rays are covered 
every plan year. The Plan also says that the frequency limits for these services have been exceeded.  
 
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 frequency limits for these services 
have been exceeded. The record shows that the Plan paid for the comprehensive evaluation that you received 
on August 22, 2019, less than 3 years ago. The record also shows that the Plan paid for bitewing x-rays that 
you received on February 7, 2020. Therefore, we decided that the Plan does not have to pay for the 
comprehensive evaluation (D0150) and the bitewing x-rays (D0274) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for procedures on eye coded 00144 provided 
on January 23, 2020. 
 
You asked the Plan to pay for the anesthesia for procedures on eye. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00144 is anesthesia for procedures on eye; corneal 
transplant. 
 
We find that CPT code 00144 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that a corneal transplant procedure was performed to support anesthesia for procedures 
on eye, corneal transplant. The nesthesia records submitted document patient was evaluated for cataract 
surgery. Therefore, the service cannot be verified. Based on this information, we decided that Medicare rules 
for coverage of the anesthesia for procedures on eye have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia for procedures on eye coded 00144 provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2391) provided on July 2, 2020. 
 
You asked the Plan to pay for the dental service. You say that you told the dentist that you only wanted the 
exam and cleanings. You say that you advised that you could not afford additional services. You say that half 
of the cleaning took place on 2 different dates of service. You also say that you do not have the money right 
now to pay for these services. The Plan denied your request. The Plan says fillings and periapical x-rays are not 
listed as covered services. The Plan says a second cleaning in a calendar year is not covered. The Plan also says 
that the provider is not billing you for the periapical x-ray and second cleaning. 
 
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 filling is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2391) provided on 
July 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 
11, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The 
Plan says that you are responsible for the copayment. 
 
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 $265 
copayment for Medicare-covered one-way ambulance transportation.  
 
You have been asked to pay a $250.37 copayment for the ambulance transport. the ambulance transport falls 
within the Medicare-covered one-way ambulance transportation benefit category. This means that you have 
been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the ambulance transport provided on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on May 26, 2020. 
 
You asked the Plan to pay for the dental item. You say that your partial denture did not fit properly. You say 
that after multiple visits, your denture still did not fit. You say that the Plan advised you could go to a different 
dentist. You say that The Plan denied your request. The Plan says 1 partial denture is covered every 5 years. 
The Plan also says that the frequency limit has been exceeded. 
 
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 frequency limit of 1 partial denture 
every 5 years has been exceeded. The record shows that the Plan paid for a partial denture that you received on 
December 16, 2020. The record shows that you signed a treatment plan which indicates that you acknowledged 
and accepted financial responsibility prior to receiving the partial denture. Additionally, the Plan confirmed 
that the initial partial denture was not returned to the provider. Therefore, we decided that the Plan does not 
have to pay for the partial lower denture (D5214) provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services performed by a chiropractor from February 28, 
2020, to March 11, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says chiropractor 
services are limited to treatment of manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that the enrollee received an office visit on February 28, 2020, and electrical stimulation on 
February 28, 2020, March 4, 6, and 11, 2020. The services at issue are not manual manipulation of the spine. 
Services other than manual manipulation of the spine, when performed by a chiropractor, are not covered. 
Therefore, we decided that the Plan does not have to pay for services performed by a chiropractor from 
February 28, 2020, to March 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on May 16, 2019. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this procedure never 
actually took place. The Plan denied your request. The Plan says the correct copayment has been applied.  
 
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 $400 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/outpatient hospital facility 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 outpatient surgery provided by a participating provider on May 16, 2019.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
MAXIMUS to make a decision on this type of complaint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a skin substitute (15275) provided on 
February 25, 2020. 
 
You asked the Plan to pay for the application of a skin substitute. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT 15275 (2 Units) has an MUE 
value of 2, provider billed 3 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 15275 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the application of a skin substitute have not 
been met. Therefore, we decided that the Plan does not have to pay for the application of a skin substitute 
(15275) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from January 7, 2020, to May 20, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
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. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received from January 7, 2020, to May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography, transthoracic, real-time 
with image documentation (2D) (93306) and myocardial perfusion imaging, tomographic (SPECT) (78452) 
provided June 17, 2019 to June 25, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that previous annual visit 
01/25/18 billed correctly with a $40 copay. 6/17/19 visit billed incorrectly and you paid $300. You did not 
question 6/17/19 billing but you want these errors corrected. The Plan denied your request. The Plan says the 
claims processed with the correct copayments applied per the 2019 and 2020 Evidence of Coverage booklets. 
 
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 $150 
copay for covered diagnostic radiology services in the outpatient department of a network hospital or facility 
per 2019 EOC and per 2020 EOC $235 copay for each covered diagnostic procedure or test at a network 
outpatient facility.  
 
You have been asked to pay $535.00 for the diagnostic services. The diagnostic services fall 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 echocardiography, transthoracic, real-time with image documentation (2D) (93306) 
and myocardial perfusion imaging, tomographic (SPECT) (78452) provided June 17, 2019 to June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on May 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had several infected teeth. You say that 
there were no in network endodontic specialists within 75 miles that were available due to Covid-19. The Plan 
denied your request. The Plan says the provider in this case is not a network provider. The Plan says that dental 
services that you receive out of network are not covered. 
 
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, dental services that you receive out of 
network are not covered. The record shows that the Plan confirmed there were in network providers treating 
emergency cases that were available. Therefore, we decided that the Plan does not have to pay for the root 
canal (D3330) provided on May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid, digital, binaural (V5258) provided on July 31, 
2020. 
 
You asked the Plan to pay for a hearing aid. You say that the item is medically necessary. The Plan denied your 
request. The Plan says hearing aids ordered through providers other than the Plan's Hearing are not covered. 
 
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 ordered through the Plan.  
 
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 aid have not been met. Specifically, the hearing aid was not ordered through the Plan. 
Therefore, we decided that the Plan does not have to pay for a hearing aid, digital, binaural (V5258) provided 
on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, such as a skilled nursing facility, 
home with home health services, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.