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

 
We decided that the Plan does not have to waive the copayment for testosterone pellets on January 20, 2022, to 
April 21, 2022. 
 
You asked the Plan to waive the copayment for testosterone pellets. You say that you would like to appeal the 
cost share. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for testosterone pellet. The total allowed amount of the testosterone pellets is $1,817.44, resulting 
in a coinsurance amount of $363.48.  
 
You have been asked to pay a 20% coinsurance for testosterone pellets. This item/service falls within the 
Medicare Part B Prescription Drugs 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 
testosterone pellets on January 20, 2022, to April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided from 
January 5, 2022, to January 28, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the device rendered was not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PCD coded as E0676 is used only for prevention 
of venous thrombosis. 
 
We looked at the file and Medicare rules. Review of the file shows that the pre-operative appointment showed 
no evidence of swelling (edema) or a diagnosis of lymphedema. Based on this information, we decided that 
Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device (PCD) provided from January 5, 2022, 
to January 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractor visit provided on June 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a chiropractor visit. You say that this service 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 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 chiropractor visit provided on June 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you disagree with the charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,950 copayment for 6 days of inpatient hospital care. This item/service falls 
within the Inpatient hospital care 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 
inpatient hospital care provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction and limit oral evaluation (D7210, D0140) 
provided on May 12, 2022. 
 
You asked the Plan to pay for the dental extraction and limit oral evaluation. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental 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 a dental 
extraction and limit oral evaluation (D7210, D0140) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning for a patient with cognitive 
impairment provided on May 26, 2022. 
 
You asked the Plan to pay for assessment of and care planning for a patient with cognitive impairment. You 
say that the assisted living facility is responsible for obtaining prior authorization for all their patients, which 
should also cover for medical treatments provided by this doctor as it was rendered in good faith. 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 
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 assessment of and care planning for a patient with cognitive 
impairment provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 15, 2021,
under codes 87481, 87491, 87500, 87556, 87591, 86731, 87640, 87641, 87651, 87653, 87798, 87486, 87541,
87561, and 87581.
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 regarding the Place of Service (POS) code were not met.
Maximus upheld the Plans decision. The Plan requested a reopen as codes 87486, 87541, 87561, and 87581
were omitted from the first review.
The Plan is correct in this The Plan must follow Medicare rules. Medicare rules say that providers must report
services correctly. Providers must report services with the appropriate POS code. The testing at issue was billed
with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the
laboratory. Medicare billing criteria are not met. Therefore, we have decided the Plan does not have to pay for
genetic testing provided to the enrollee on June 15, 2021, under codes 87481, 87491, 87500, 87556, 87591,
86731, 87640, 87641, 87651, 87653, 87798, 87486, 87541, 87561, and 87581.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from February 2, 2022, 
to May 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that a referral is not needed for the services 
that were rendered to the enrollee. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 the psychotherapy services provided from 
February 2, 2022, to May 25, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan has to pre-approve the Maze radiofrequency ablation (RFA) procedure to be 
providing along with an approve aortic valve replacement. 
 
You asked the Plan to pre-approve the Maze RFA procedure. You say that it is felt that this should be allowed 
in addition to the valve replacement to address the enrollee's atrial fibrillation. The Plan denied your request. 
The Plan says that the service at issue is experimental and/or unproven and 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 the Maze RFA procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male with atrial fibrillation and moderate-to-severe valvular heart 
disease. The enrollee has been approved for aortic valve replacement, and as such, it would be reasonable for 
the cardiac surgeon to carry out a Maze procedure at the same time. In summary, simultaneous Maze procedure 
to address the enrollee's atrial fibrillation would be considered medically reasonable in this patients clinical 
management. 
 
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 Maze RFA procedure have not been met. Therefore, we decided that the 
Plan has to pre-approve the Maze radiofrequency ablation (RFA) procedure to be providing along with an 
approve aortic valve replacement.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on May 
19, 2022. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you should not be 
charged a copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. This item/service 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 copayment for a 
physical therapy visit provided on May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 8, 2022, to February 26, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay 
since you were not satisfied with the physician's performance of the surgery. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $285 
copayment per day for days 1 to 6 for inpatient hospital care.  
 
You have been asked to pay a $285 copayment per day for days 1 to 6 and $0 per day for days 7 to 90 for 
inpatient hospital care. You are being charged $285 for 6 days which equals to $1710.00 however you are 
being charged $1386.86 which is less than the required amount. 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 inpatient hospital care provided on February 8, 2022, to February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided January 16, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not call for the 
ambulance so you should not have to pay. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $220 
copayment for ambulance services.  
 
You have been asked to pay a $220 copayment for ambulance services. This item/service 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 ambulance services 
provided January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0220, D0150, D0230, D0274) provided on 
June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services (D0220, D0150, D0230, D0274) provided on June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 99239. 
 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 99233 
is a column II code to column I code 99239. 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 99233 billed for date of service May 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33508 billed for date of service July 13, 
2021. 
 
You asked the Plan to pay for procedure code 33508. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 33508 is bundled into payment for code 33533. 
 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 33508 
is a column II code to column I code 33533. 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 33508 billed for date of service July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair received from May 24, 2022, to June 23, 
2022. 
 
You asked the Plan to pay for the wheelchair. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item is not a covered benefit when received from a provider who is not 
Medicare certified. 
 
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 the wheelchair received from May 24, 
2022, to June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 26, 2022. 
 
You asked the Plan to pay for the ultrasound. 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. 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 76705 is ultrasound, abdominal, real time with image 
documentation; limited (eg, single organ, quadrant, follow-up). 
 
We find that CPT code 76705 is not supported in the medical record. Specifically, this service was billed with 
place of service 22 (on-campus outpatient hospital). However, the documentation shows that the enrollee was 
inpatient for this date of service. This means this service was billed with an incorrect place of service. Based on 
this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, 
we decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray image (D0330) provided on June 15, 
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 date of service March 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray image (D0330) provided on 
June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code 12002. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 12002 is bundled into payment for code 26720. 
 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 12002 
is a column II code to column I code 26720. 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 12002 billed for date of service January 19, 
2022.