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

 
We decided that the Plan does not have to pay for the resin-based composites (D2392) for teeth # 4 and 5 
provided on May 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are unable to find information on your 
dental coverage online. The Plan denied your request. The Plan says resin based composite is not listed as a 
covered service. 
 
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, resin-based composites are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composites (D2392) for teeth # 4 and 5 provided on May 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for imaging services provided to the enrollee 
on May 15, 2020. 
 
You asked the Plan to waive the coinsurance for the services. You say that you are very cautious with income. 
The Plan denied your request. The Plan says the cost-sharing was applied correctly according to your benefits 
and the services rendered. 
 
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 diagnostic radiology services.  
 
You have been asked to pay 20% coinsurance ($52.54) for the services. The services fall within the diagnostic 
radiology 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 coinsurance for imaging services 
provided to the enrollee on May 15, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulvestrant. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not supported by NCCN guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found Fulvestrant is FDA 
approved for the treatment of HR-positive, HER2-negative advanced or metastatic breast cancer (in 
combination with ribociclib) in postmenopausal women as initial endocrine-based therapy or following disease 
progression on endocrine therapy. Based on the results of the Monaleesa-3 trial and extrapolation results from 
the second-line setting, the NCCN Panel has included fulvestrant in combination with CDK 4/6 inhibitors as a 
category 1 first-line option for postmenopausal. You have advanced disease and meets criteria for the use of 
fulvestrant as monotherapy or in combination with a CDK 4/6 inhibitor. The service is reasonable and 
medically necessary. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Fulvestrant.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on October 1, 2019. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for esophageal cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360? molecular pathology genomic profiling provided to the enrollee on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of tissue from 6 or more finger or toe nails 
(99213, 11721) provided on January 28, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of tissue from 6 or more finger or toe nails. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of tissue from 6 or more finger or toe 
nails (99213, 11721) provided on January 28, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections of tendon sheath, ligament, or muscle 
membrane (99213, 20550) provided on February 24, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the injections of tendon sheath, ligament, or muscle membrane. You say that you 
made a mistake with the type of insurance the patient carried and are now aware. The Plan denied your request. 
The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 injections of tendon sheath, ligament, or 
muscle membrane (99213, 20550) provided on February 24, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have a fear you will fall in the bathroom. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9501) provided 
December 14, 2019 to December 20, 2019. 
 
You asked the Plan to pay for the home infusion therapy services. You say that please see the attached signed 
orders for review and claim reconsideration. The Plan denied your request. The Plan says invalid procedure 
code for this service. 
 
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 S9501 is home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9501 is not supported in the medical record. Specifically, Medicare guidance says 
procedure code S9510 has a status code ?I? is not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services (S9501) provided December 14, 2019 to December 20, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental items. You say that you are in pain because you are without 
dentures. You say that your previous dentures were too big and would fall out while talking. You say that your 
arthritis and temporomandibular joint (TMJ) pain have worsened since not wearing dentures. The Plan denied 
your request. The Plan says dentures are covered once every  plan years. The Plan says the frequency limit for 
dentures has been reached. 
 
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 and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan previously 
approved a complete upper denture and lower partial denture on October 10, 2018. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5212).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided on February 27, 
2020 and February 28, 2020. 
 
You asked the Plan to pay for the outpatient therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Medicare says that all therapy services must include the 
corresponding therapy modifier, GP or GO. Based on this information, we decided that Medicare rules for 
coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for the outpatient therapy services provided on February 27, 2020 and February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 24, 
2020 to March 27, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $325 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay $650, which is less than the total copayment amount for an inpatient hospital stay. 
An inpatient hospital stay 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an inpatient hospital stay from March 24, 2020 to March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiation therapy services you received 
from May 28, 2020, through June 8, 2020. 
 
You asked the Plan to waive the copayment for the radiation therapy services. You say that you do not think 
you should be responsible for this copayment.  You say that you didn't have a copayment when you had 
different insurance last year. The Plan denied your request. The Plan says this copayment was assessed 
correctly since the plan confirmed you did receive radiation therapy services from this provider. 
 
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 $60 
copayment for therapeutic radiology services.  
 
You have been asked to pay a $60 copayment for the radiation therapy services. The radiation therapy services 
fall within the therapeutic radiology 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 the radiation therapy services you received from May 28, 2020, through June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance (D6080) provided on June 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that this service has been covered in the past. You 
also say that you need this service due to tarter build up. The Plan denied your request. The Plan says this claim 
was initially coded as prophylaxis. The Plan says the claim was corrected implant maintenance as you have no 
natural teeth, thus prophylaxis would not be needed. The Plan also says implant maintenance is not a covered 
service. 
 
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, implant maintenance is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
maintenance (D6080) provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided by a 
participating provideron May 11, 2020. 
 
You asked the Plan to waive the copayment for telehealth services. You say that this was an annual wellness 
exam. 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 $10 
copayment for physician/practitioner services/primary care physician.  
 
You have been asked to pay a $10 copayment for telehealth services. When services go beyond an annual 
wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. 
Telehealth services falls within the physician/practitioner services/primary care physician 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 telehealth services provided by a participating provider on 
May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
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 $0 
copayment for mammography and ultrasounds and a $200 copayment for all other diagnostic and nuclear 
medicine radiological services.  
 
You have been asked to pay a $200 copayment for an MRI. An MRI falls 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 
an MRI provided on May 27, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine 
(72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has pain and radiculopathy with 
tingling that has failed multiple therapies. Surgical intervention may be required. An MRI is reasonable and 
necessary. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).  
 
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 needle electromyography rendered on March 5, 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 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 95887 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met.  
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). 
We find that CPT code 95886 is not supported in the medical record. Specifically, the documentation does not 
support the billing of an additional unit of bilateral needle electromyography. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the needle electromyography rendered on March 
5, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on May 
25, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the emergency room did 
not render you any service. The Plan denied your request. The Plan says the correct copayment was 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 $90 
copayment for each visit for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit (99283) on May 25, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.