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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no payment can be made for these services 
as they are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
September 1, 2021, have been met. Specifically, no medical records have been provided to indicate the 
enrollees medical necessity for the requested services. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on September 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 21, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 27, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not pre-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 services at issue in this appeal. 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 genetic testing provided on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray exam of the ankle (73610) 
provided on October 27, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
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 per visit to a specialist. If other medical services or covered drugs are provided during the visit, a 
separate cost sharing for those items will apply. Enrollees must pay a $20 copayment for most x-rays and 
ultrasounds except as specified. If the same service type is performed at the same session, more than once, only 
one copayment will be applied.   
 
You have been asked to pay a $20 copayment for the x-ray exam of the ankle provided during a specialist visit. 
The Plan contract states that if other medical services or covered drugs are provided during a specialist visit, a 
separate cost sharing for those items will be applied. 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 x-ray exam of the ankle (73610) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to noble metal (D6242) for 
teeth #4 and #5 and retainer crown - porcelain fused to noble metal (D6752) for teeth #3 and #6 for a fixed 
bridge from teeth 3-6. 
 
You asked the Plan to pre-approve pontics and retainer crowns for a fixed bridge. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested services do not comply with the 
established dental clinical criteria that establishes that teeth should be free from periodontal problems. 
 
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. The Plan covers pontics and 
retainer crowns for a fixed bridge when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns for a fixed 
bridge. Our reviewer says that the fixed bridge is not reasonable and medically necessary.  Our physician reviewer found that a review of the documentation indicates that teeth #'s 3 and 6 have significant bone loss (>50%) which compromises the prognosis of these teeth to support a fixed bridge. The documentation does not support the criteria for coverage for a fixed bridge replacing teeth #'s 4 and 5 due to the poor periodontal prognosis of the abutment retainers #3 and 5. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontics and retainer crowns for a fixed bridge have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pontic - porcelain fused to noble metal (D6242) for teeth 
#4 and #5 and retainer crown - porcelain fused to noble metal (D6752) for teeth #3 and #6 for a fixed bridge 
from teeth 3-6.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the psychosocial rehabilitation services to be provided
by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The
Plan denied your request. The Plan says this provider is out-of-network and there is an in-network provider
readily available and accessible to the enrollee.
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
the psychosocial rehabilitation services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of posterior segmental instrumentation 
(22852). 
 
You asked the Plan to pre-approve the removal of posterior segmental instrumentation. You say that this is 
medically necessary. The Plan denied your request. The Plan says this procedure is already covered. 
 
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 removal of posterior segmental 
instrumentation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the removal of the original rods and screws is already 
covered by the new fusion code for the level. The removal code cannot be billed separately. There is no 
medical need for this service to be performed a second time.  
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 removal of posterior segmental instrumentation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the removal of posterior segmental 
instrumentation (22852).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services to be provided by an oral surgeon. You say that these 
services are medically necessary. The Plan denied your request. The Plan says dental services provided by an 
oral surgeon will not be covered. 
 
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 when they are not performed by a participating general dentist. 
Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an oral 
surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the walker and sales tax (S9999) provided on 
March 30, 2021. 
 
You asked the Plan to pay additionally for the walker and sales tax. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says they have approved payment for the 
walker to apply your correct coinsurance, however, the sales tax is not payable by Medicare or the Plan. 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 Durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the walker, totaling $89. The walker falls within the 
Durable medical equipment 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. 
 
The rules also say contractors do not make any additional payment for sales taxes. We looked at the file and 
Medicare rules. Medicare does not make separate payment for sales tax. Therefore, we decided that the Plan 
does not have to pay additionally for the walker and sales tax (S9999) provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that you believe that up to 3 dental cleanings are 
covered per calendar year. You say that your dental provider recommended you receive cleanings every 4 
months. You also say that you feel this service should be covered. The Plan denied your request. The Plan says 
prophylaxis is covered twice per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 and prophylaxis is covered twice per 
plan year, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you 
received on April 27, 2021, and August 11, 2021. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis (D1110) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the application of TheraSkin. 
 
You asked the Plan to pre-approve the application of TheraSkin. You say that TheraSkin application is 
medically necessary. The Plan denied your request. The Plan says that the clinical evidence in published peer-
reviewed medical literature is insufficient to show that TheraSkin is an effective treatment for open wounds. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the application of TheraSkin. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found TheraSkin is medically necessary, because of the specifics of Mohs procedure in 
this patient. 
 
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 application of TheraSkin have been met. Therefore, we decided that the Plan 
has to pre-approve the application of TheraSkin.  
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services.
You asked the Plan to waive this cost share. You say that you believed you were an inpatient and that this cost
share was not correct. The Plan denied your request. The Plan says this cost share was charged based on the
services billed by the provider and the Plan contract agreement. We overturned the Plans denial. The Plan
requested a reopen and stated that we did not apply the correct contract language. The Plan says that this
claim was processed with a payment of $3930 to the provider and a member cost share of $120. The provider
has billed this claim as outpatient emergency room services with no admission to the hospital. The case file
includes the appealed claim that shows the provider has billed with the Type of Bill 131 for Outpatient
Hospital. The Evidence of Coverage explains on page 65, there will be a $120 copayment for Emergency
Room Services.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $120 copayment for emergency room services.
The medical records show you were not admitted to the hospital. 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 $120 copayment
for emergency room services provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance, (L4) and (L5) (CPT code(s): 64635 and 64636). 
 
You asked the Plan to pre-approve the services. You say that you are unable to take pain medications and the 
procedure is medically necessary. The Plan denied your request. The Plan says your request is not medically 
necessary because your records show that you have not had two medically reasonable and necessary successful 
test blocks at the requested areas. 
 
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 services. Our physician reviewer 
found there is no documentation of prior diagnostic MBBs at the level proposed for RFA. Therefore, the 
request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance, 
(L4) and (L5) (CPT code(s): 64635 and 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on August 10, 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 procedure code 28047 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. 
 
In this case, the CPT Code Manual definition of code 28047 is radical resection of tumor (eg, sarcoma), soft 
tissue of foot or toe; 3 cm or greater. 
We find that CPT code 28047 is not supported in the medical record. Specifically, there is no documentation of 
a radical resection of a tumor (sarcoma) of soft tissue of the foot or teo for 3 centimeters or greater. 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 surgical services rendered on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transport services provided to the enrollee on May 21, 2021.
You asked the Plan to pay for these services. The Plan says this claim must be submitted to the enrollee's
primary insurer at the time of service. Maximus overturned the Plans denial for insufficient information in the
case file. The Plan requested a reopen and provided additional information. The Plan states an explanation of
benefits from the primary insurer must be submitted to the Plan before they can review this service for
payment.
The Plan is correct in this case. The Plan has met its obligation with regards to coordination of benefits.
Specifically, the Plan has identified the primary insurer and attempted coordination of benefits.
As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has
denied the claim for these services and provided an explanation of benefits. Therefore, we decided that the Plan
does not have to pay for transport services provided to the enrollee on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services coded with D2915 you received on 
November 23, 2021. 
 
You asked the Plan to pay for dental code D2915. You say that you believe this is a covered service. The Plan 
denied your request. The Plan says this service is not covered under your dental benefit. The Plan has paid for 
the dental services coded with D0140 and D2920 billed on the same date of service. 
 
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 contract says that 
only those dental codes listed in the contract are covered.  Code D2915 is not listed as a covered code. 
 
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 dental 
services coded with D2915 you received on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic x-ray provided on November 15, 2021. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you believe this should be covered due to 
medical necessity. The Plan denied your request. The Plan says that this benefit was exhausted at the time the 
services were rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan indicated that this benefit had been exhausted as this type of x-ray is 
only covered once every two years. Though you admit in your appeal that you did receive an x-ray about one 
year ago, the Plan did not provide evidence to show that this x-ray was panoramic, nor the date on which it was 
provided. We requested this missing information and did not receive a response. Without this, we find that the 
denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the panoramic x-ray 
provided on November 15, 2021.  
 
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.