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

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
December 19, 2022. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that the lab mixed up 
your blood samples and were told to go to the emergency room. 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 $75 
copayment for emergency care.  
You have been asked to pay a $75 copayment for the emergency room service. This item/service falls within 
the emergency 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 the emergency room 
service provided on December 19, 2022. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 17, 2022, to 
May 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there is an NOA on file. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from April 17, 2022, to May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical examination (G0438), provided on July 
27, 2022. 
 
You asked the Plan to pay for an annual physical examination. You say that the service should be covered. The 
Plan denied your request. The Plan says this benefit has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual physical examination (G0438), provided 
on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) 
provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 May 18, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) 
provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the billed code is an accepted procedure code. 
The Plan denied your request. The Plan says that the proof of delivery is not valid. 
 
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. 
 
We looked at the file and the rules. The Plan states that proof of delivery and an itemized bill were provided in 
a different case number. However, the Plan did not include the submitted documentation to substantiate their 
denial for this case. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the durable medical equipment billed for date of service October 9, 2022.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft. 
 
You asked the Plan to pre-approve VIA Disc procedure. You say that you have a disc out of alignment. The 
Plan denied your request. The Plan says there is insufficient evidence of efficacy for this procedure. 
 
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 VIA Disc procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the VIA Disc allograft is experimental for back pain, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve VIA Disc allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatology specialist office visit 
provided on November 23, 2022. 
 
You asked the Plan to waive the copayment for the dermatology specialist office visit. You say that you should 
not have to pay since you only were seen by a nurse. 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 $30 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $30 copayment for the dermatology specialist office visit. This item/service falls 
within the in-network specialist physician/practitioner 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. The medical records show you were seen by a 
specialist. Therefore, we decided that the Plan does not have to waive the copayment for the dermatology 
specialist office visit provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for the billed services. You say that this is not a duplicate claim. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that a new patient visit, 99203, performed by the same provider, was billed and paid for in 2021. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99204 billed for date of service October 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure will be beneficial for the enrollee. 
The Plan denied your request. The Plan says the efficacy of this device has not been established, and Vertiflex 
is contraindicated for the enrollee. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the coding is correct. The Plan denied your 
request. The Plan says the code 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 95870 is needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters. 
 We find that CPT code 95870 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95870 billed for date of service October 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 home health services provided on October 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 31, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 0003A billed for date of 
service July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace provided on October 07, 
2022. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that this should not be considered a 
prosthetic device. 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 20% 
coinsurance for in-network prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the back brace. This item/service falls within the in-network 
prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. According to Medicare the back brace (code L0637) is considered a prosthetic 
device. The total you owe is $164.96 ($824.80 allowed amount x 20% coinsurance = $164.96). Therefore, we 
decided that the Plan does not have to waive the coinsurance for the back brace provided on October 07, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone (code G2068) provided on 
September 12, 2022. 
 
You asked the Plan to pay for a take-home supply of methadone. You say that you have been enrolled in the 
Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
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. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for a 
take-home supply of methadone (code G2068) provided on September 12, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership purchased from 
November 1, 2022, through December 31, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as you 
purchased a membership through a participating fitness center. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because you purchased a membership through 
a participating fitness center. An annual reimbursement allowance is paid towards memberships at  
non-participating fitness clubs and exercise centers only. Therefore, we decided that the Plan does not have to 
issue reimbursement for the gym membership purchased from November 1, 2022, through December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement or re-bond implant/abutment supported crown 
(D6092) provided on October 10, 2022. 
 
You asked the Plan to pay for dental implant. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered 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. 
 
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 recement 
or re-bond implant/abutment supported crown (D6092) provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not the standard of care for the enrollee's condition. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling data to suggest that proton therapy is superior to - or more 
beneficial than - intensity-modulated/image-guided radiation therapy (IMRT/IGRT). Th generally accepted 
standard of care for prostate cancer is to only offer proton beam therapy on clinical trials and to not routinely 
offer it to patients. While guidelines consider proton therapy a reasonable alternative, they do not describe it as being necessary in lieu of non-proton based treatment and are quite explicit in that there is no evidence of its 
superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on December 23, 2022. 
 
You asked the Plan to pay for the office visit (99213). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
provided on December 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling with a Licensed Mental Health Counselor 
(LMHC) provided on November 2, 2022, through November 20, 2022. 
 
You asked the Plan to pay for the counseling. You say that the service is medically necessary. The Plan denied 
your request. The Plan says a Licensed Mental Health Counselor (LMHC) is not certified with Medicare. 
 
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 counseling with a Licensed Mental 
Health Counselor (LMHC) provided on November 2, 2022, through November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 09, 2022.