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

We decided that the Plan does not have to reduce the $100 cost share charged for physician services and an
injection on June 27, 2022.
You asked the Plan to reduce this cost share. The Plan denied your request. The Plan says this cost sharing was
charged correctly. Maximus overturned the Plans denial. The Plan requested a reopen and provided a
breakdown of the services rendered. The Plan noted that you were charged $40 for code 99204 which is the
office visit and $60 for code 67028 which is the Intravitreal injection which can be separately billed by the
physician. This totals your $100 liability.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay any cost share associated
with a service provided. Your physician billed you for the office visit and an administered injection. You have
been asked to pay the correct amount based on your contract with the Plan and the claim for payment submitted
by the provider for each service rendered.
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 adjust the $100 cost share charged for physician services and an injection
provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 23, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that the copayment 
for this service would be waived. 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 each visit to a speciality physician office. 
 
You have been asked to pay a $35 copayment for a specialist visit. This item/service falls within the each visit 
to a speciality physician office 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 
specialist visit provided on March 23, 2022.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for genetic testing provided April 28, 2022, to May 5, 2022
(minus any applicable cost share).
You asked the Plan hold you harmless for genetic testing. You say that you had no way of knowing that the
provider was not part of the physician's office who took the blood sample. The Plan denied your request. The
Plan says that the Medicare criteria for this testing were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.
We still believe this testing should be covered, because it appears to have been ordered by a contract provider,
your treating physician. The Plan has not indicated that the testing was not ordered by a contract provider, only
that the lab itself that performed the test was out of network. Medicare rules say that a contract provider is an
agent of the plan. Services and referrals given by a contract provider are considered approved by the plan
unless notice is provided that the services will not be covered. The Plan follows these rules.
You saw your contract provider and they took a blood specimen. The file does not show that the Plan provided
notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing provided is
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for genetic
testing provided April 28, 2022, to May 5, 2022 (minus any applicable cost share).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), mechanical traction 
therapy (97012), and the electrical stimulation (97032) provided from November 2, 2021, through  
November 30, 2021. 
 
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 these services are not a covered benefit. 
 
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 therapeutic exercises (97110), mechanical traction therapy (97012), 
and the electrical stimulation (97032) provided from November 2, 2021, through November 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
14, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum system, flex walk system and a multiaxial 
ankle. 
 
You asked the Plan to pre-approve a vacuum system, flex walk system and a multiaxial ankle. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are 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 pre-approve a vacuum system, flex walk system and 
a multiaxial ankle. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the requested prosthetic 
components at issue in this case meet all of Medicare's LCD criteria for medically reasonable and necessary for 
the enrollee. Provided medical records from the treating provider do not support the vendor's statements that 
the requested components are medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vacuum system, flex walk system and a multiaxial ankle have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vacuum system, flex walk system and a 
multiaxial ankle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on November 9, 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 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 November 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on 
November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the shower chair and the grab bar purchased 
on October 31, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items are not payable as they 
purchased from an ineligible provider. 
 
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. 
 
A 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 issue reimbursement for the shower chair and 
the grab bar purchased on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid (V5261) purchased from the 
out-of-network (OON) provider on October 20, 2021. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item was purchased from an 
out-of-network provider, without 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 issue reimbursement 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 had network providers available 
who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that 
the Plan does not have to issue reimbursement for the hearing aid (V5261) purchased from the out-of-network 
(OON) provider on October 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia (J8499). 
 
You asked the Plan to pre-approve Kerendia. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says Kerendia is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kerendia (J8499).  
 
Benefits for Kerendia may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you were going to have the x-
ray done at the time of this visit. 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. This benefit includes the 
requested bitewings - four radiographic images (D0274) but is limited to one set per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D0274 was exhausted on date of service May 4, 2022. Therefore, we 
decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
November 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no clear description of the 
enrollees headaches and no noted frequency of the enrollees headaches. The enrollee has previously received 
Botox for her headaches and appears to currently take sumatriptan for her headaches. There is no 
documentation of anticonvulsant use or beta-blocker use. As such, the documentation does not establish a 
mycobacterium avium-intracellulare (MAI) for the use of Botox or shown that the enrollee has tried and failed 
the health plans step-criteria for Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing-one-three teeth, per 
quadrant (D4342) x4, localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381) x7, gingival irrigation-per quadrant (D4921) x4, and drugs or 
medicaments, dispense in the office for home use (D9630) x2 provided on November 2, 2022. 
 
You asked the Plan to pay for dental services. You say that you are appealing the denial of payment for 
services you received. The Plan denied your request. The Plan says these services are not covered under your 
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. Periodontal scaling and root 
planing-one-three teeth, per quadrant (D4342), localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation-per quadrant (D4921), and 
drugs or medicaments, dispense in the office for home use (D9630) are not covered under the Plans dental 
benefits. 
 
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 
periodontal scaling and root planing-one-three teeth, per quadrant (D4342) x4, localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) x7, 
gingival irrigation-per quadrant (D4921) x4, and drugs or medicaments, dispense in the office for home use 
(D9630) x2 provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on October 4, 
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 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 bone 
replacement graft (D7953) provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic and retainer crown (D6740, D6245) provided on 
November 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 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 pontic 
and retainer crown (D6740, D6245) provided on November 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelstar Mixject. 
 
You asked the Plan to pre-approve Trelstar Mixject. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Trelstar Mixject. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trelstar Mixject have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Trelstar Mixject.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on April 19, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the supporting patient report supports the 
medical necessity for this service. The Plan denied your request. The Plan says the claim was not received 
within the 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance service was not filed until December 2, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, and the frames 
provided on September 14, 2022. 
 
 You asked the Plan to pay for the polycarbonate lens, the progressive lens, and the frames. You say that you 
were told that the provider was in-network. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when one purchase and fitting of eyeglasses and pair of lenses or 
contact lenses, one per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, you had already received eyewear under claim number 
111277319000 on September 14, 2022, which exhausted the benefit. Based on this information, we decided 
that the Plan's rules for coverage of the polycarbonate lens, the progressive lens, and the frames have not been 
met. Therefore, we decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, 
and the frames provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intradialytic Parental Nutrition. 
 
You asked the Plan to pre-approve Intradialytic Parental Nutrition. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that parenteral nutrition 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 pre-approve Intradialytic Parental Nutrition. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intradialytic Parental Nutrition have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Intradialytic Parental Nutrition.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 9, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
71046. 
 
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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service November 9, 
2022.