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

 
We decided that the Plan does not have to waive the deductible for an in-network specialist visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you should not have to pay this 
deductible. The Plan denied your request. The Plan says the deductible amount applied was correct. 
 
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 $250 
deductible before the Plan pays anything for Physician/Practitioner Services, Including Office Visits.  
 
You have been asked to pay $86.77 of the $250 deductible for a specialist visit. A specialist visit falls within 
the Physician/Practitioner Services, Including Office Visits 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 deductible for an in-network specialist visit provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on July 9, 2021. 
 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of infiltrating 
lobular carcinoma of the right breast for which she received five years of antiestrogen therapy. The enrollee's 
CA 20729 has been rising. A recent CT PET did not reveal any area of involvement. The available 
documentation does not support that the enrollee has either recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer, has not been previously tested with the same test using NGS for the same 
cancer genetic content, and has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). The 
testing was therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 testing rendered on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 
11, 2022. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says the CPT code was 
previously paid. 
 
The Plan must follow Medicare rules. The 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. The file includes evidence that CPT code 74176-26 was billed and 
paid by the Plan on January 20, 2022. Comparison of the two claims shows these are exact duplicates. There is 
no evidence presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 11, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service October 24, 2021. 
 You asked the Plan to pay for procedure code 93042. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 12032. 
 
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, we have confirmed that code 93042 
is a column II code to column I code 12032. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service October 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Colonoscopy on February 21, 2022. 
 
You asked the Plan to waive the copayment for Colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 $300 
copayment for outpatient hospital visits. If a screening colonoscopy results in biopsy or removal of any 
growth/polyp during the procedure, the member cost share for outpatient surgery will not be applied. See 
Colorectal cancer screening for cost-sharing for screening colonoscopies. 
 
You have been asked to pay a $300 copayment for Colonoscopy. Colonoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 Colonoscopy on February 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the tertiary care. You say that you do not know if there is an in-network 
provider who can provide the proper care for the enrollee. The Plan denied your request. The Plan says the 
rendering provider that was requested is an OON provider. The service has been approved and the enrollee has 
been redirected to an in-network provider to receive the services they require. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
tertiary care to be provided 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 services (99442-95-25) provided on September 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed modifier is 
not supported. 
 
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 99442-95-25 is not supported in the medical record. Specifically, this was the only code 
billed on this date of service. Modifier -25 is used to report a significant, separately identifiable E/M service. 
Since there was no other code billed on this date of service, modifier -25 is not supported. 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 the services (99442-95-25) provided on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Hospital visit January 19, 2022. 
 
You asked the Plan to waive the copayment for Hospital visit. You say that you were not aware that the plan 
does not do retro authorizations. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
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 $195 
copayment for outpatient hospital visit. Covered services include, but are not limited to: X-rays, Radiation 
(radium and isotope) therapy including technician materials and supplies, Surgical supplies, such as dressings, 
Splints, casts and other devices used to reduce fractures and dislocations, Laboratory tests, Blood  including 
storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood 
that you need, and other outpatient diagnostic tests. The provider billed in the amount of $22,662.30 and the 
allowed amount is $6,259.29. The Plan paid $6,134.29. Therefore, results in the total cost-sharing amount of 
$125. This is less than the copayment amount. 
 
 You have been asked to pay a $125 copayment for Hospital visit, which is less than the copayment amount. 
Hospital visits 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 Hospital visit January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested bone marrow aspirate is 
medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspirate is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not medically necessary. Our physician reviewer found the 
enrollee was being treated for spinal stenosis. She presented with significant pain in the back radiating to her 
legs. She has a hard time walking. The exam reveals very slight weakness with extensor hallucis longus 
strength bilaterally. There is some weakness with dorsiflexion on the left, which is about 4+/5. The plan 
approved the L4-5 laminectomy, decompression, and fusion. 
 
However, detailed documentation is not evident regarding a specific indication to support the request for bone 
marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested bone marrow aspirate in the setting of L4-5 
laminectomy, decompression, and fusion, in this case, is not medically reasonable or 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from September 9, 2021, 
through December 12, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that you are fully aware the provider is out-of-
network. The Plan denied your request. The Plan says these services are only covered when obtained through a 
Plan contracted 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 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 for chiropractic services provided from September 9, 
2021, through December 12, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet the guidelines for long term acute 
care services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving and requires only additional short-term acute care services that can 
safely be completed at the current facility until more appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 5, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift chair provided on February 12, 2022, by a retail 
provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for a seat lift chair. You say that you were informed by a representative of the Plan 
that the item at issue would be covered at 80 percent. The Plan denied your request. The Plan says rules for 
payment have not been met because the provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a seat lift chair provided on February 12, 
2022, by a retail provider not enrolled in the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed to the enrollee.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria were not met. Maximus partially overturned the Plans
denial. The Plan requested a reopen and provided additional claim information for review. The Plan
demonstrated that code J3490 was processed and paid on February 24, 2022, under a separate claim number. A
copy of the paid Provider Remittance Advice was attached for review. Procedure code 99215-25 was denied
for "Claim Already Processed" on July 12, 2021. This code was previously paid to the same provider on May
18, 2021. A copy of the paid Provider Remittance Advice and claim image was attached for review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case the Plan has provided documentation to show these services were
previously paid. Therefore, we decided that the Plan does not have to pay for these services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and heel stabilizer (L3170) 
provided on February 22, 2022. 
 
You asked the Plan to pay for the orthoses. You say that you would like this claim reprocessed and approved 
for payment based on the submitted documentation. The Plan denied your request. The Plan says 
documentation required for payment is missing. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation does not indicate that the ordering provider discussed the medical 
need for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the ankle foot orthosis (L1971) and heel stabilizer (L3170) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous surgery (including flap entry and closure) 
(code D4260) and a bone replacement graft (code D4263). 
 
You asked the Plan to pre-approve the osseous surgery and graft. You say that you desperately need this 
surgery to stabilize your periodontal disease. The Plan denied your request. The Plan says the requested 
services are not covered under your supplemental dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
osseous surgery (including flap entry and closure) (code D4260) and a bone replacement graft (code D4263).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 22, 2022.
You asked the Plan to waive the copayment for specialist office visit. You say that you only saw the nurse practitioner and not the doctor so it should be covered. The Plan denied your request. The Plan says the copayment applied is correct.
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 $15 copayment for each visit to a specialist. You have been asked to pay $15 copayment for specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided March 17, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that you feel this service was needed as 
a result of an accident. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond crown (D2920) provided March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation services (D9222, D9223) provided on July 3, 2020.
You asked the Plan to pay for the deep sedation services. You say that the services should be covered. The Plan denied your request. The Plan says the claim processed correctly.
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 deep sedation services are not among those covered under this benefit when they are provided with other services not covered under the dental benefit. Therefore, we decided that the Plan does not have to pay for the deep sedation services (D9222, D9223) provided on July 3, 2020.