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

We decided the Plan does not have to pay for ambulance transport provided on December 24, 2021.

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan says that the provider has billed ambulance services with diagnosis code S72.301S for Unspecified fracture of shaft of right femur, sequela. The diagnosis billed is inappropriate for the service.
A sequela (7th character "S") code cannot be reported as the first listed/primary diagnosis on a claim because
coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by
the sequela (7th character "S") code.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim was submitted with an inappropriate diagnosis code. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on December 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound provided on May 6, 2022.
You asked the Plan to waive the deductible for an ultrasound. You say that the service on the claim states it
was an ultrasound examination of the abdominal back wall, and this is not true; you had an ultrasound for the
kidney. The Plan denied your request. The Plan says this cost sharing was charged correctly.
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 $233 in-network and out-of-network combined deductible which
applies to an ultrasound.
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $233 in-network and out-of-network combined deductible which
applies to an ultrasound. This cost sharing is a contractual obligation that had not been met at the time an
ultrasound was received on May 6, 2022. The record shows this claim was approved, and you are responsible
for a cost sharing amount. Therefore, we decided that the Plan does not have to waive the deductible for an
ultrasound provided on May 6, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Percutaneous Left Atrial Appendage Closure
(LAAC) with Watchman for the enrollee.
You asked the Plan to provide coverage for this device. You say that at the time of the appeal, the device was
medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Percutaneous Left
Atrial Appendage Closure (LAAC). The Maximus Physician Reviewer determined that LAAC insertion was
reasonable and medically necessary in this case. The Plan requested a reopen and stated that there is no
documentation that the enrollee or the requesting facility is enrolled in a prospective, national, audited registry
that: 1) consecutively enrolls LAAC patients, and 2) tracks the following annual outcomes for each patient for
a period of at least 4 years from the time of the LAAC. The medical records show the enrollee is a 71-year-old
man with a medical history that includes atrial fibrillation, GI bleeding, subdural hematoma, heart disease,
diabetes, and pulmonary disease. It is documented that the enrollee cannot take blood thinners. The risks and
benefits of left atrial closure (LAAC) with Watchman were discussed.
Our Medical Director determined that the Plan is correct in this case. The case file does not contain sufficient
documentation to support that the enrollee is enrolled in or that the facility participate in, a prospective,
national, audited registry that consecutively enrolls LAAC patients, and tracks the following annual outcomes
for each patient for a period of at least 4 years from the time of the LAAC: Operator-specific complications,
Device-specific complications including device thrombosis, Stroke, adjudicated, by type, Transient Ischemic
Attack (TIA), Systemic embolism, Death, and Major bleeding, by site and severity. NCD 20.34 states that
LAAC is non-covered for the treatment of NVAF when not furnished according to the above-noted criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not
have to provide coverage for a Percutaneous Left Atrial Appendage Closure (LAAC) with Watchman for the
enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) services (97161) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the PT services. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered OON.

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 physical therapy (PT) services (97161) to be provided 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 intraoral x-rays (D0210) and the comprehensive 
periodontal evaluation (D0180) provided on June 15, 2022. 
 
You asked the Plan to pay for the intraoral x-rays (D0210) and the comprehensive periodontal evaluation 
(D0180). You say that the services were received for medical purposes and should be covered. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
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 pay for the 
intraoral x-rays (D0210) and the comprehensive periodontal evaluation (D0180) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gum surgery (D4266), an implant placement 
(D6010), an abutment (D6056 and D6060), and a bone replacement graft (D7953) for tooth #12. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the dental implants and all associated services, gum surgery, and bone replacement grafts are not 
covered by the Plan. 
 
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 
gum surgery (D4266), an implant placement (D6010), an abutment (D6056 and D6060), and a bone 
replacement graft (D7953) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the teeth #22-27 are not compromised 
due to major caries or substantial fracture. The submitted radiographs (x-rays) show some attrition of the 
incisal edges possibly due to wear from the opposing porcelain restorations on the upper anterior teeth but there 
is at least 90% healthy tooth structure remaining. There is no evidence of any pathology or necessity for the 
requested porcelain crowns. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoe supplies (codes A5512 and A5500) provided to the
enrollee on November 22, 2021.
You asked the Plan to pay this claim. You say that these inserts should be covered by the Plan. The Plan denied
your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial
for insufficient information in the case file. The Plan requested a reopen and stated that the provider billed
this service inappropriately with a diagnosis code of E11.9 for Type 2 diabetes mellitus without complications,
and L97.509 for non-pressure chronic ulcer of other part of unspecified foot with unspecified severity. The
second Diagnosis Code of L97.509 is inconsistent with the modifier billed. The provider has billed LT/RT, to
identify item provided for the left/right side of the body and KX to indicate that the clinician attestation.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when required the
appropriate modifiers. In this case, this claim cannot be paid as billed due to an issue with the modifier billed.
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for shoe supplies (codes A5512 and A5500) provided to the enrollee on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions 
(D7310), a non-intravenous conscious sedation (D9248), an application of desensitizing medicament (D9910), 
an immediate maxillary denture (D5130), and an immediate mandibular denture. 
 
You asked the Plan to pre-approve an alveoloplasty in conjunction with extractions (D7310), a non-intravenous 
conscious sedation (D9248), an application of desensitizing medicament (D9910), an immediate maxillary 
denture (D5130), and an immediate mandibular denture. You say that you received notice of the denial of your 
dentures and teeth extractions due to no coverage for dental. The Plan denied your request. The Plan says the 
plan allows for the coverage of limited dental services and the requested codes are covered if member has a 
dental plan rider. The Plan also says that the member does not have a dental plan rider. 
 
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 for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in 
conjunction with extractions (D7310), a non-intravenous conscious sedation (D9248), an application of 
desensitizing medicament (D9910), an immediate maxillary denture (D5130), and an immediate mandibular 
denture.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 18, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the facility requested your 
services and typically they handle any authorizations, if needed, and the services would fall under the facility 
authorization. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
 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 subsequent nursing facility care provided on July 
18, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the radiologic examination, of 
the spine, entire thoracic and lumbar, including skull, cervical and sacral spine; 2 or 3 views (72082) provided 
on April 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the radiologic examination, of the spine, 
entire thoracic and lumbar, including skull, cervical and sacral spine; 2 or 3 views (72082) provided on April 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychological evaluation provided on June 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychological evaluation. You say that this is medically necessary and should 
be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 a psychological evaluation provided on June 22, 
2022, 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, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x 2) for tooth #1, #14 provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on claim # 0037017166, when the plan paid 
for 6 out of 8 extractions. Therefore, we decided that the Plan does not have to pay for the extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) for tooth #1, #14 provided on March 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for the outpatient hospital services rendered on October 25, 2021.
You asked the Plan to pay for any of 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 stated that for code 71260 was denied because the claim lacked a
required modifier, and the claim was returned to the provider for correction. The Plan notes that when one or
more edits are needed on a claim, the entire claim can be returned to the provider for correct and review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when necessary, the
required modifiers. In this case, this claim could not be paid as billed due to several required edits needed on
the claim. Medicare rules for coverage of any of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the outpatient hospital services rendered on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 2D 
oral/facial photographic image (D0350) provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the comprehensive oral 
evaluation provided has already been exhausted. Additionally, the 2D oral/facial photographic image provided 
is not a covered benefit. 
 
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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service May 5, 2021.  
Specifically, the Plan provides coverage for a comprehensive oral evaluation once every three years. You 
previously received this service on May 5, 2021, which was paid for by the Plan.  Therefore, you have exhausted the allowable benefit for this service. Additionally, the 2D oral/facial 
photographic image provided is not a covered benefit. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and the 2D oral/facial photographic image (D0350) provided on 
June 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 30, 2022, to April 29, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an 
appropriate NOA claim was submitted incorrectly for the period of care at issue. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from January 30, 2022, to April 
29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford these 
copayments. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
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 
copayment for each ambulance trip. You had 5 ambulance trip(s). The Plan charged you $1248.83 for these 
services, which is less than the total copayment amount. Your maximum out of pocket (MOOP) was not met 
yet at this time. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on March 16, 2022.
You asked the Plan to pay for the hearing aids. You say that this was your second set of hearing aids in 14
years. You say you do not see where your 2022 benefit had been used. The Plan denied your request. The Plan
says the claim was paid correctly.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only up to a $1,500 allowance.
We looked at this physician's review, the file, and the Plan's rules. Specifically, the record shows the Plan paid
$1,500 towards the hearing aids. Based on this information, we decided that the Plan's rules for coverage of the
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids
provided on March 16, 2022.