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

 
We decided that the Plan does not have to waive the copayments for the three ultrasound services you had on 
January 13, 2020. 
 
You asked the Plan to waive the copayments for the three ultrasound services. You say that you should be 
reimbursed for these services since you paid for them upfront. The Plan denied your request. The Plan says you 
were reimbursed correctly with the exception of your required cost sharing for these services. 
 
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 $100 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.  
 
Records show that you had three different radiology services on January 13, 2020.  You had a duplex scan of 
the extremity veins (represented by procedure code 93970), a duplex scan of the lower extremity arteries 
(represented by procedure code 93925), and a limited bilateral nonivasive physiologic study of the upper or 
lower extremity arteries (represented by procedure code 93922). The plan charged you a $100 for the first two 
of these studies.  The copayment for the third study was limited to $52.39, because that is the total allowed 
amount for this service.  Since the allowed amount is lower than the $100 copayment laid out in your Evidence 
of Coverage, you have only been charged the allowed amount for this service.   You have been asked to pay a 
$100 copayment for each the three ultrasound services. This cost sharing is applied per service, not per date of 
service. 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 copayments for the three ultrasound services you had on 
January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from October 21, 2019 
through October 28, 2019 by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there are in-network providers of these services available and there 
does not appear to be exceptional circumstances to require this out-of-network provider. 
 
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 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. 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 medical services provided from October 21, 
2019 through October 28, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
extraction (D7140), surgical extraction (D7210), and removal of residual tooth roots (D7250) provided on May 
6, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, extractions, and removal of residual 
tooth roots. You say that these services were needed due to an infection. You also say that these services were 
not for cosmetic reasons. The Plan denied your request. The Plan says these services are not covered by the 
Plan. The Plan also says that you did not opt to purchase an Optional Supplemental Benefit package. 
 
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 
problem focused limited oral evaluation (D0140), extraction (D7140), surgical extraction (D7210), and 
removal of residual tooth roots (D7250) provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcranial Doppler study rendered on February 27, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare has established limited coverage for billed 
diagnoses for procedure code 93886.  
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 93886 with ICD-
10 diagnosis codes I49.3 (ventricular premature depolarization) and R55 (syncope and collapse). These 
diagnosis codes are not ones for which Medicare covers the billing of code 93886. Therefore, we decided that 
the Plan does not have to pay for the transcranial Doppler study rendered on February 27, 2020.  
 
The Plan references Local Coverage Article (LCA) A57592 in their determination; however, this LCA is not 
binding for Part B Medicare and was not used in the MAXIMUS determination.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on March 14, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the facility arranged for the transportation. 
The Plan denied your request. The Plan says there is no authorization on file for the ambulance service. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the transportation services at issue in this appeal. The Plan did not pre-approve the 
services at issue. There are no records showing the services were urgent or emergent. We found no exception 
that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay 
for the transportation services provided on March 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction-erupted tooth requiring removal of 
bone and/or sectioning of tooth provided on May 29, 2020. 
 
You asked the Plan to pay for the surgical extraction. You say that you have had this plan for 40 years and the 
service wasn't covered in your first attempt to use dental benefits. You say that this should be covered. The 
Plan denied your request. The Plan says only simple extractions are covered. 
 
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, surgical extractions are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical 
extraction provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (67515) provided on December 2, 2019. 
 
You asked the Plan to pay for an injection. You say that this code is supported by the records. The Plan denied 
your request. The Plan says this code is no documented. 
 
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 67515 is injection of medication or other substance into 
Tenon's capsule. 
 
We find that CPT code 67515 is not supported in the medical record. Specifically, the operative note does not 
contain documentation that this injection was performed. Based on this information, we decided that Medicare 
rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not have to pay 
for an injection (67515) provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on August 7, 2019. 
 
You asked the Plan to pay for the eye refraction. You say that the provider just did the refraction because that is 
how you find out what lenses you need. The Plan denied your request. The Plan says the services received were 
not routine. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. According to the chart notes from August 7, 2019, you went 
in for blurry vision. A complete exam and refraction were performed. It was determined to be cataracts, no 
surgical intervention recommended at this time. You were given a new prescription for new lens. As a result, 
this was billed as a medical exam. Your EOC states that Original Medicare doesnt cover routine eye exams 
(eye refractions) for eyeglasses/contacts. The health plan contract says that enrollee's pay a $0 copayment for 
one non-Medicare covered routine eye exam, including refractions, every calendar year. Therefore, we decided 
that the Plan does not have to pay for the eye refraction provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy rendered on May 12, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered. 
 
We looked at the file and Medicare rules. The services at issue are infrared therapy. These services are not 
covered by Medicare for any condition. Therefore, we decided that the Plan does not have to pay for the 
infrared therapy rendered on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 21, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan coded 72125 provided on February 4, 2020. 
 
You asked the Plan to pay for the CT scan. 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 72125 is computed tomography, cervical spine; without 
contrast material. 
 
We find that CPT code 72125 is not supported in the medical record. Specifically, the documentation supports 
one unit of this code, which was previously approved and paid by the plan. There is no additional 
documentation supporting an additional study was performed. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the CT scan coded 72125 provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 6, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were informed out-of-network benefits 
could be used for the provider. You say that the representative could not find information stating that the 
services wouldn't be covered under the out-of-network benefit. The Plan denied your request. The Plan says 
payment cannot be issued for services performed by a provider that 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 the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dental services provided on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent urinary catheter, with insertion supplies (CPT 
Code A4353), male external catheter, with or without adhesive, disposable, each (CPT Code A4349), skin 
barrier, wipes or swabs (CPT Code A5120) and gloves, non-sterile, per 100 (CPT Code A4927) provided on 
October 27, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met. 
 
Healthcare Common Procedure Coding System (HCPCS) code A4353-KX (200 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice with patient signature, or 
proof of delivery to corroborate with the delivery ticket. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A4349-KX (35 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice with patient signature, or 
proof of delivery to corroborate with the delivery ticket. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A5120-AU (50 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice with patient signature, or 
proof of delivery to corroborate with the delivery ticket. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code A4927-KX (2 Units) remains not supported. 
The documentation submitted did not include an itemized shipping/billing invoice with patient signature, or 
proof of delivery to corroborate with the delivery ticket. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information.  
 
Therefore, we decided that the Plan does not have to pay for intermittent urinary catheter, with insertion 
supplies (CPT Code A4353), male external catheter, with or without adhesive, disposable, each (CPT Code 
A4349), skin barrier, wipes or swabs (CPT Code A5120) and gloves, non-sterile, per 100 (CPT Code A4927) 
provided on October 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on November 4, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support hospital discharge day management of more than 30 minutes was performed. A 
documented duration of time of 31 minutes or more is required to support this code. Based on this information, 
we decided that Medicare rules for coverage of the hospital discharge day management services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management 
services coded 99239 provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 24, 2019. 
 
You asked the Plan to pay for the wound care supplies (A6021). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines 
for inpatient services. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that 
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an 
enrollee. 
 
Records show that the wound care supplies was used in a SNF. Therefore, we decided that the Plan does not 
have to pay for wound care supplies provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthoses, and suspension 
sleeves provided on February 4, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthoses (L1851), and suspension 
sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the 
Delivery Ticket did not include the tracking number and the Proof of Delivery did not include details to 
corroborate the Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. A description of the 
items delivered must be noted on the Proof of Delivery. 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 lumbar-sacral orthosis, the knee orthoses, and suspension sleeves provided on February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0428 and A0425) provided on May 
14, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says with the 
information submitted, it cannot be determined whether the services were medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the transportation services have not been met. Specifically, the documentation submitted 
does not include sufficient information to determine whether payment is due or the amount of payment. 
Therefore, we decided that the Plan does not have to pay for transportation services (A0428 and A0425) 
provided on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on 
January 7, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services of an assistant surgeon, co-surgeon, or surgical team are not covered for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
43243. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on January 
7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 13, 2019 by an 
out of network provider. 
 
You asked the Plan to pay for the medical services provided by an out of network provider. You say that the 
Plan should pay this claim. The Plan denied your request. The Plan says the services were non-urgent and you 
did not request prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on December 13, 2019 by an out of network 
provider.