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

 We decided that the Plan does not have to pay for massage therapy (97124) provided on April 11, 2019 through 
May 4, 2019. 
 
You asked the Plan to pay for the massage therapy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says per CMS guidelines, this code always requires 
a therapy modifier- GP, GO or GN. 
 
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 CPT code 97124 is not supported in the record. Specifically, per CMS CPT code 97124 is a 
therapy code. A GP, GO or GN modifier must be reported with therapy codes. This submitted claim does not 
include the required GP, GO or GN modifier. Based on this information, we decided that Medicare rules for 
coverage of the massage therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for massage therapy (97124) provided on April 11, 2019 through May 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 2, 2019 to June 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. 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. The Plan says that the member's primary care physician did not refer these services.
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 lab work provided on April 2, 2019 to June 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2750) for tooth #'s 20 and 21. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says that there is no 
evidence of pathologic destruction of the teeth warranting crown replacements. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable. 
 
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 crowns. Our reviewer says that the 
crowns are medically necessary. Our physician reviewer found the criteria for coverage for replacement crowns 
for teeth #'s 20 and 21 due to the fracture of the existing porcelain have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-
approve crowns (D2750) for tooth #'s 20 and 21.
Appeal type: Supplemental Benefit
Decision: Favorable

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 these dental services. You say that these dental services should be covered by the
Plan. The Plan denied your request. The Plan says the dental services provided were not eligible for coverage.
Maximus overturned the Plan's denial. The Plan requested a reopen and stated that page 71 of the Evidence of Coverage (EOC) stating Crowns are limited to 1 per tooth per 5 years. The Plan states that your benefit for this service was exhausted on May 1, 2019 which is less than 5 years from the date of service in question. The Plan states the Explanation of Benefits (EOB) submitted to Maximus shows that the Plan paid for the crown on tooth number 10 for date of service May 1, 2019 and May 8, 2020. The Plan is correct in this case. 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, this service was not available for
coverage at the time it was received. Therefore, we decided that the Plan does not have to pay for dental
services provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 22, 2019. 
 
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 were not pre-certified. 
 
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 lab services provided to the enrollee on January 
22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on November 8, 
2019. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you disagree with the charges 
because you were told that the visit would be free. 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. Your 
contract with the Plan says that there is a $599 deductible for out-of-network physician/practitioner services, 
including doctor's office visits.  
 
You had a specialist visit on November 8, 2019 with an out-of-network provider. Therefore, you are 
responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had paid 
$0 toward the $599 deductible. Therefore, you are responsible to pay the total allowed amount of $163.52.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $599 deductible for out-of-network physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a 
specialist visit was received on November 8, 2019. Therefore, we decided that the Plan does not have to waive 
the deductible for a specialist visit provided on November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ultrasound provided on December 5, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for a diagnostic ultrasound. 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 a diagnostic ultrasound provided on December 5, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the medical eye exam provided on January 28, 2020. 
 
You asked the Plan to waive the deductible for the medical eye exam. You say that you were never told that 
you would have to pay anything for the office visit. The Plan denied your request. The Plan says that you have 
been charged the correct cost sharing amount. 
 
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 enrollees must pay a $0 copayment for each Medicare-covered exam to 
diagnose and treat diseases or conditions of the eye.  
 
The Plan says you must pay a $153.25 towards the deductible for the medical eye exam. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 copayment for the medical eye exam. The record 
shows that the Plan applied the $198 deductible for Part D drugs to the medical eye exam. Therefore, we 
decided that the Plan has to waive the deductible for the medical eye exam provided on January 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for PT provided from March 23, 2020 to April 
17, 2020. 
 
You asked the Plan to waive the copayments for PT. You say that you disagree with the charges because you 
have never paid in the past and cannot afford 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 $40 
copayment for outpatient rehabilitation services.  
 
You received PT from March 23, 2020 to April 17, 2020 for a total of 20 visits. Therefore, you are responsible 
to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 20 (PT visits) = $800 
 
You have been asked to pay the total copayment amount of $800 for PT. PT falls within the outpatient 
rehabilitation 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 copayments for PT 
provided from March 23, 2020 to April 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on December 12, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment due to medical necessity. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 physician services provided on December 12, 
2019 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 extraction and deep sedation/general anesthesia services 
provided on January 31, 2020. 
 
You asked the Plan to pay for the extraction and deep sedation/general anesthesia services. You say that you 
spoke to a Plan representative and were told you would receive a partial reimbursement for this procedure. You 
also say that you were not informed that this provider did not accept Medicare. The Plan denied your request. 
The Plan says the treating provider is a Medicare opt out provider. The Plan also says that services from 
Medicare opt out provider are not covered under your plan. 
 
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 
the extraction and deep sedation/general anesthesia services provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided 
February 20, 2020. 
 
You asked the Plan to pay for an automatic external defibrillator. You say that clinical documentation and 
medical studies are included within the attachments to substantiate the medical necessity of the LifeVest. The 
Plan denied your request. The Plan says this was reported without a required diagnosis. 
 
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 K0606 is an automatic external defibrillator. 
 
We find that CPT code K0606 was billed inappropriately  due to the claim being  billed without the required 
valid diagnosis code. Based on this information, we decided that Medicare rules for coverage of an automatic 
external defibrillator have not been met. Therefore, we decided that the Plan does not have to pay for an 
automatic external defibrillator (K0606) provided February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 14, 2019. 
 
You asked the Plan to pay for the laboratory 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 laboratory services provided on May 14, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine services provided on 
March 10, 2020. 
 
You asked the Plan to waive the copayment for nuclear medicine services. You say that you disagree with the 
charges because you feel that the Plan did not pay enough toward the claim. 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 $490 
copayment nuclear medicine services provided in an outpatient hospital facility. 
 
You received nuclear medicine services on March 10, 2020 at an outpatient hospital facility. Therefore, you are 
responsible to pay the $490 copayment.  
 
You have been asked to pay a $490 copayment for nuclear medicine services. Nuclear medicine 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 nuclear medicine services provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on October 22, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 physician services provided to the enrollee on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from 
February 15, 2020 at 10:06am through February 16, 2020. 

You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the review has determined that post stabilization care services at the non-participating plan 
facility after 10:06 a.m. on February 15, 2020 were not medically necessary and reasonable. The enrollee was 
hemodynamically stable for ambulance transport with monitoring to a Plan facility. The post-stabilization care 
services from February 15, 2020 at 10:06am through February 16, 2020 were not medically necessary and 
reasonable. The review has determined that the treating physician did not document (in the physician notes, on 
a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from February 15, 2020 at 10:06am 
through February 16, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 11, 2020. 
 
You asked the Plan to pay for a domiciliary, rest home visit. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 a domiciliary, rest home visit provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 7, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician 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 to you by an out-of-network provider on February 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 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 the medical services provided to you by an out-of-network provider on February 13, 2020.