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

We decided that the Plan does not have to pay forthe electroencephalogram services (95955 and 95813) provided on June 24, 2019.You asked the Plan to pay forthe electroencephalogram services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the services billed.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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).The CPT code Manual definition of code95813 is Electroencephalogram (EEG) extended monitoring; 61-119 minutes. We asked our coder 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 electroencephalogram services. Our reviewer says that CPT codes 95955 and 95813 do not meet criteria for billing or reimbursement consideration. Our reviewer found the technical report did not include documentation to support electroencephalogram during nonintracranial surgery and extended electroencephalogram monitoring.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram services have not been met.Therefore, we decided that the Plan does not have to pay forthe electroencephalogram services (95955 and 95813) provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waive the cost share for the office visit, Betamethasone acetate
injection and wrist brace provided on August 6, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct and is too
expensive. The Plan denied your request. The Plan says you received specialist office surgery ($25), a
Medicare Part B injection ($3.02) and a wrist brace ($11.20). The Plan states the cost share for each item and
service was charged based on your Plan contract agreement. We overturned the Plan's denial because a
Plan contract was not submitted for review. The Plan requested a reopen and submitted the appropriate Plan
contract for review. The Plan is correct in this case. 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 cost share for each service or item provided during this
visit. 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 cost share for the office visit, Betamethasone acetate injection and wrist brace
provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dental services.You asked the Plan to pre-approvethe dental services. You say that you need these services. You say that you have oral damage caused by cancer, surgeries, radiation treatments and Sjogren's disease. You also say that you will benefit from these services to continue safe medical treatmentsand quality of life.The Plan denied your request. The Plan says the requested services are dental in nature. The Plan also says that routine dental services are not covered by the Plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid forby Medicare.Therefore, we decided that the Plan does not have to pre-approvethe dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and 5 additional periapical x-ray (D0230) provided on August 11, 2020.You asked the Plan to pay forthe dental services. You say that your 2020 Evidence of Coverage shows that the periapical x-rays are covered.The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says that you are not enrolled in the supplemental dental rider.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 forthe initial periapical x-ray (D0220) and 5 additional periapical x-ray (D0230) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveporcelain/ceramic crown (D2740) and post and core in addition to crown (D2952).You asked the Plan to pre-approveporcelain/ceramic crown and post and core in addition to crown. You say that these services are medically necessary.The Plan denied your request. The Plan says these are not covered benefits under your supplemental plan.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 pre-approveporcelain/ceramic crown (D2740) and post and core in addition to crown (D2952)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a nonparticipating provider on October 20, 2020.You asked the Plan to waive the deductible for a diagnostic colonoscopy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct deductible amount has been applied.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 $750 deductible for outpatient surgery. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time a diagnostic colonoscopy was received on October 20, 2020. The total amount you are being asked to pay is $456.27. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed.Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a nonparticipating provider October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on August 24, 2020, by out-of-network providers.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says the providers are out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.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 had network providers available who could have provided 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 forthe medical services provided to the enrollee on August 24, 2020, by out-of-network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compressiondevice (E0652) and segmental pneumatic appliance (E0667).You asked the Plan to pay fora pneumatic compression device and appliance. You say that this equipment is deemed Medically necessary and prescribed for treatment of the enrollee's lymphedema (stage II).The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture, one or more needles, initial 15 minutes (97810) acupuncture, one or more needles, each additional 15 minutes (97811) provided on July 17, 2020 to August 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe acupuncture services. You say thatacupuncture is the only remedy which has worked for you as you were given medications back in 2013-2015 which only gave you an upset stomach. You should not be responsible for the visits.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.Medicare rules say that plans canrequire 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 had network providers available who could have provided 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 foracupuncture, one or more needles, initial 15 minutes (97810) acupuncture, one or more needles, each additional 15 minutes (97811) provided on July 17, 2020 to August 3, 2020 by an out of network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427, A0425)
provided August 10, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you didn't call the
ambulance so the copayment should be waived. The Plan denied your request. The Plan says the correct
copayment was applied for the service that was 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 a $225
copayment for ambulance services.
You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls
within the ambulance services benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an
ambulance transport (A0427, A0425) provided August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSpinal Bone Growth Stimulator (E0748).You asked the Plan to pre-approvethe spinal bone growth stimulator. You say that the services should be approved, it was multilevel surgery.The Plan denied your request. The Plan says to meet coverage the enrollee should be 9-months post-op from most recent spinal surgery, in order for the request to be approved. It was in November 2020.The Plan follows Medicare rules. Medicare rules say that at least nine months must have elapsed since the most recent surgery or it must be a multilevel spinal infusion or where there is a history of a previously failed spinal fusion at the same site.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 spinal bone growth stimulator. Our reviewer says that the service is not medically necessary. Our physician reviewer found Medicare criteria were not met. There were less than nine months elapsed since the last surgery and there was less than three levels of infusion, making it not a multilevel spinal fusion surgery.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 spinal bone growth stimulator have not been met.Therefore, we decided that the Plan does nothave to pre-approveSpinal Bone Growth Stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary or rest home visits (99336) rendered by the out of network (OON) provider onMarch 17, 2020andMarch 31, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plandenied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 forthe domiciliary or rest home visits (99336) rendered by the out of network (OON) provider on March 17, 2020 and March 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay fornon-emergent vision services provided on India from February 1, 2020, to March 9, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says these were outpatient vision services that were not provided in an emergent or urgent situation out of the country. Maximus overturned the Plans decision. The Plan requested a reopen and stated that outpatient physician servicesand lab services for cataract consultation are not considered emergent or urgentservices needed to stabilize a life-threatening condition. The Plan is correct in this case. 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 only urgent or emergent services to stabilize a life-threateningevent are for covered worldwide. Vision services provided in India for the evaluation of cataracts are not considered to be urgent or emergent services out of the country. Therefore, we decided that the Plan does not have to pay fornon-emergent vision services provided on India from February 1, 2020, to March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure provided on September 14, 2020.You asked the Plan to pay forthe preventive procedure. You say that dental is included in your plan.The Plan denied your request. The Plan says this service is 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe preventive procedure provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays of the wrist and foot (73110, 73630) provided on September 22, 2020.
You asked the Plan to pay for the x-rays. You say that you would like reconsideration because the member had multiple exams on the same date. The Plan denied your request. The Plan says the submitted documentation supports one unit each of 73630-26-LT and 73110-26-RT, which were previously approved/paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Specifically, the record supports one unit of CPT code 73760 and CPT code 73110. These services have already been processed and paid by the Plan. There is no evidence of additional services being rendered. Therefore, we decided that the Plan does not have to pay for the x-rays of the wrist and foot (73110, 73630) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon September 14, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 physician's services. 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 September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 12, 2020.You asked the Plan to pay forthe dental services. You say that this was not an emergency visit. You say that the enrollee would like the $56 balance of your $200 allowance to be applied to the visit. You say that this was a normal visit because the enrollee had some pain. You also say that you did not say that the enrollee was in severe pain.The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that the periapical x-ray is not listed as a covered service either. The Plan also confirmed with the provider that you signed a pay agreement showing that you agreed to be responsible for all services rendered on your behalf.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 forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 12, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for SNFservices provided from July 1, 2020, throughJuly 9, 2020.You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.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 servicesat 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 SNF services provided from July 1, 2020, through July 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S1015 and S8301) provided to the
enrollee on September 1, 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 these are invalid procedure codes for these services.
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 the denied codes is:
S1015:
Iv tubing extension set
S8301:
Infection control supplies, not otherwise specified
We find that the denied codes are not supported in the medical record. Specifically, these codes have a status
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services
have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S1015
and S8301) provided to the enrollee on September 1, 2020.