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

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on July 25, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were told there would be 
no copayment because you were going from one facility to another. 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 $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for an ambulance trip. A copayment is applied to every 
ambulance trip provided; therefore, the correct copayment has been applied. An ambulance trip 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 trip 
provided by a participating provider on July 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a lab test to determine blood clotting time 
(85610) performed on March 11 and May 21, 2020, and a primary care provider office visit (99211) on June 
11, 2020. 
 
You asked the Plan to waive the copayments for blood-clotting tests and a primary care provider office visit. 
You say that these copayments are too high. The Plan denied your request. The Plan says the correct 
copayments were 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 $15 
copayment for Medicare-covered lab services and a $15 copayment for each Medicare-covered primary care 
provider office visit. 
 
You have been asked to pay a $4.38 copayment per test for blood-clotting tests and a $15 copayment for a 
primary care provider office visit. Blood-clotting tests fall within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. A primary care provider office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have 
been asked to pay less than or equal to the full 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 a lab test to determine blood clotting time (85610) performed on 
March 11 and May 21, 2020, and a primary care provider office visit (99211) on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a continuous glucose machine (CGM) and related supplies (CPT 
K0553 and K0554) billed for date of service January 24, 2020. 
 
You asked the Plan to pay for the CGM and related supplies. You say that the records provided support the 
items billed. The Plan denied your request. The Plan says that the charge exceeds the fee schedule/ maximum 
allowable fee arrangement. The Plan says that the procedure modifier was invalid on the date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not substantiate their denial reason. A dispute 
regarding allowed amount does not justify a complete denial or reversal of payment. The records show that the 
modifier billed was KF, and that this modifier is valid beginning on July 1, 2019. The plan has not thoroughly 
explained their denial reason, nor have they provided supporting evidence that there was anything that 
warranted a denial of the items in dispute. Therefore, we decided that the Plan has to pay for a continuous 
glucose machine (CGM) and related supplies (CPT K0553 and K0554) billed for date of service January 24, 
2020.  
 
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 established outpatient office visit of 25 minutes (99214) 
provided on April 28, 2020 to May 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered are medically necessary to 
continue your prescriptions. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an 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 established outpatient office visit of 25 
minutes (99214) provided on April 28, 2020 to May 22, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI you received on July 3, 2020. 
 
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says the MRI was not 
medically necessary. 
 
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 pay for the MRI. Our reviewer says that the 
requested MRI was not medically reasonable and necessary. Our physician reviewer found that there is no 
documentation that an MRI of the shoulder was medically reasonable and necessary as there was no plain x-ray 
of the left shoulder documented in the records. An x-ray of the shoulder would be necessary before proceeding 
to an MRI in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for the MRI you received on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjacent tissue transfer (14021) provided on November 5, 
2019. 
 
You asked the Plan to pay for the adjacent tissue transfer. 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 service 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 14021 is adjacent tissue transfer or rearrangement, scalp, 
arms and/or legs; defect 10.1 sq cm to 30.0 sq cm. 
 
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 adjacent tissue transfer. Our reviewer says that CPT code 
14021 does not meet criteria for billing or reimbursement consideration. Our coder found the medical records 
provided do not include documentation of an Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; 
defect 10.1 sq cm to 30.0 sq cm being performed on November 5, 2019, therefore this service cannot be 
verified. 
 
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 adjacent tissue transfer have not been met. Therefore, we decided that the 
Plan does not have to pay for an adjacent tissue transfer (14021) provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on November 18, 2019. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 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 the Guardant360 testing provided on November 
18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on December 
10, 2019. 
 
You asked the Plan to pay for the critical care 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
include a critical care progress note for the billed date of service of December 10, 2019. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on 
December 10, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (72141) of the cervical spine. 
 
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 has not been 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 MRI is indicated based on the radicular nature 
of pain. 
 
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 (72141) of the cervical spine.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 8, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you were charged $40 for an 
emergency visit but it was called an oral evaluation. You say that insurance hasn't paid anything in 2020 thus 
far. The Plan denied your request. The Plan says oral exams are only covered once every three plan years. 
 
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, you also have a maximum benefit of 
one oral exam every three plan years. The Plan paid for a limited oral evaluation provided on June 5, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on January 21, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the 
facility. 
 
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 skilled nursing services provided on January 21, 
2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 27, 2020, to 
March 31, 2020 billed with HIPPS code 5AHKS. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be covered. The Plan 
denied your request. The Plan says this was not billed with a valid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that starting in January 2020, Medicare uses a new 
set of 432 HIPPS codes.  
 
CMS maintains a Master List of home health HIPPS codes. While the billed HIPPS code was valid from 2008 
to 2019, it is no longer listed as a valid code for dates beyond January 1, 2020. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from March 27, 2020, to March 31, 2020 
billed with HIPPS code 5AHKS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 12, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage of comprehensive genomic profile testing is limited to one test per specimen. 
 
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 claim provided does not show the coding and billing guidance has been followed.  
 Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on 
February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
18, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that the exam and x-rays 
were desperately needed. You say that the comprehensive exam should be paid. The Plan denied your request. 
The Plan says per your dental benefits, you can have the procedure once every three plan years. 
 
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, you also have a maximum benefit of 
one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation 
provided on May 18, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) provided on June 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
May 31, 2019 out of network. 
 
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 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 outpatient mental health 
services provided to the enrollee on May 31, 2019 out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 21, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 
psychotherapy 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 psychotherapy services provided on February 21, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 17, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the patient was seeking care 
with your providers who are able to come into the skilled nursing facility to provide care for patients who are 
unable to leave the facility. The Plan denied your request. The Plan says all non-emergent services received 
with a non-Plan provider require approval by the Plan prior to the services being rendered. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care provided on June 17, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvean oral occlusive device.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewersays that the services are medically necessary. Our physician reviewer found the submitted records show that you have a diagnosis of degenerative arthritis of the temporomandibular joint (TMJ). You have received treatment for the pain associated with TMJ that is no longer effective. Placement of an occlusal splint to relieve pressure on the joint is the standard of care for your condition and is not being requested for the treatment of teeth or the supporting structures of the teeth. The services are 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 these services have been met.Therefore, we decided that the Plan has to pre-approvean oral occlusive device. Local Coverage Determination (LCD) L33611 and Local Coverage Article (LCA) A52512 referenced by the Plan are not valid for the services at issue and were not used in the MAXIMUS determination.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.