Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2330, D2331, D2392) provided on August 4, 
2021, the extraction (D7140) provided on August 13, 2021, the core buildup (D2950) provided on October 1, 
2021, and the dental bridge (D6740, D6245) and crown (D2740) provided on October 22, 2021. You asked the 
Plan to pay for the dental services. You say that you were unhappy with the care provided by 
this office, and you would like the money you paid back. The Plan denied your request. The Plan says the 
fillings and extraction are covered services, and you are responsible for 50% coinsurance for these services. 
These claims have been covered and processed correctly, and your coinsurance has been assessed in 
accordance with your contract. Crowns, core buildups, and dental bridge services are not covered by your 
dental benefit. 
 
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 only the 
services listed in the Dental Benefits Chart section of the contract. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core buildup, crown and 
dental bridge services are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the core buildup (D2950) provided on October 1, 2021, and the dental bridge (D6740, 
D6245) and crown (D2740) provided on October 22, 2021.  
 
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 50% 
coinsurance for covered dental extractions and covered fillings.  
 
You have been asked to pay 50% coinsurance for each of the fillings and the dental extraction. 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 pay any additional amount for the fillings (D2330, D2331, D2392) provided on August 4, 
2021, and the extraction (D7140) provided on August 13, 2021. 
 
Your complaint about the quality of services provided by a Plan-contracted dental provider is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the compression stockings identified with 
code A6531 that were issued on April 27, 2021, and May 9, 2021, and the ACE knee brace purchased on 
October 2, 2021. 
 
You asked the Plan to provide reimbursement for the compression stockings and elastic knee brace. You say 
that these items are medically necessary for your conditions and should be reimbursed by the Plan. The Plan 
denied your request. The Plan says these items are not covered by Medicare for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. In 
addition, the knee brace is not eligible for coverage is it is not rigid or semi-rigid. Therefore, we decided that 
the Plan does not have to provide reimbursement for the compression stockings identified with code A6531 
that were issued on April 27, 2021, and May 9, 2021, and the ACE knee brace purchased on October 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Automatic external defibrillator provided on December 28, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Automatic external defibrillator. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 Automatic external defibrillator provided on 
December 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acupuncture provided on August 24, 2021.
You asked the Plan to provide coverage for acupuncture for left hand pain. You say that acupuncture was
medically necessary. The Plan denied your request. The Plan says neither Medicare nor the Plan covers
acupuncture for left hand pain. The records also so not show you had prior authorization for these services.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
The Plan is correct in this case. Medicare and the Plan only cover acupuncture for low back pain. The Plan
contract states that some acupuncture services require prior authorization. Both your appeal and the records
show treatment for left hand pain. Medicare coverage criteria were not met. Therefore, we decided that the Plan
does not have to provide coverage for acupuncture provided on August 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry by ultrasound echography, A-scan; 
with intraocular lens power calculation (CPT code 76519) provided on September 28, 2021, by the provider. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include documentation of Ophthalmic biometry by 
ultrasound echography, A-scan; with intraocular lens power calculation; therefore, the billed service cannot be 
verified. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found the case file does not contain 
documentation of Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power 
calculation. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation 
(CPT code 76519) provided on September 28, 2021, by the provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prothrombin time (PT) and partial thromboplastin time (PTT) testing provided on August 10, 2021.
You asked the Plan to pay for the PT/PTT testing. You say that these tests should be paid due to medical necessity. The Plan denied your request. The Plan says it was decided to approve payment for one date of service, but the other date of service remains denied.
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PT/PTT testing have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the prothrombin time (PT) and partial thromboplastin time (PTT) testing provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An injection provided on December 10, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An injection. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
were 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 An injection provided on December 10, 2021 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs, and was treated for pain. The enrollee was at a moderate to maximal assist level for 
functional mobility. The enrollee does not require skilled nursing or therapy services on a daily basis. She does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee still has evidence of neurologic involvement 
with encephalopathy and requires ongoing acute care services. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT 
code 81479-90-GY) provided on February 25, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the claim 
should be paid. The Plan denied your request. The Plan says the service is not covered as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
There is no order for the testing and no notes on file requesting the genetic testing. Therefore, we decided that 
the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT code 81479-90-
GY) provided on February 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Positron Emission Tomography (PET) scan
for the initial treatment of prostate cancer for the enrollee.
You asked the Plan to provide coverage the requested PET scan. You say that a PET scan is medically
necessary for the initial treatment of prostate cancer. The Plan denied your request. The Plan says Medicare
does not cover PET scans for the initial treatment of prostate cancer. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not follow the NCD appropriately.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that does not cover
PET scans for the initial treatment of prostate cancer. Therefore, we decided that the Plan does not have to
provide coverage for a Positron Emission Tomography (PET) scan for the initial treatment of prostate cancer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) 
rendered by the out-of-network (OON) provider on February 21, 2022. 
 
You asked the Plan to pay 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 the service was rendered by 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 pay for care 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the telephone evaluation and management service (99442) rendered by the out-of-
network (OON) provider on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation discharge day management services (procedure 
code 99217) provided to the enrollee on November 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says since a qualifying initial or subsequent observation care service, or another service resulting in 
an observation stay has not been reported, the discharge service is being denied. 
 
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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found CPT 99217 was reported with any 
subsequent care documentation. In this case, observation discharge services would not be covered, when no 
care during this stay is documented. 
 
We looked at this coder'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 pay for observation discharge day management services (procedure code 99217) provided to the 
enrollee on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a rabies injection (90375) provided on 
September 9, 2021. 
 
You asked the Plan to waive the coinsurance for the rabies injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services 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 40% 
coinsurance for Out-of-network Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 40% coinsurance for the rabies injection (allowed amount is $2,177.25 x 40% = 
$870.90). The record indicates that the services were performed in an out-of-network facility. 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 coinsurance for a rabies injection (90375) provided on September 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from April 19, 2021 to April 23, 
2021 billed with DRG 469. 
 You asked the Plan to pay for inpatient services billed with DRG 469. You say that the services were billed 
correctly and payment should be rendered. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 469. 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 pay for inpatient services billed with DRG 469. Our reviewer says that the services were 
not medically necessary. Our physician reviewer found the progress notes supported the enrollee had a possible 
history of saturation changes in the post operative setting from a previous surgery, and also it was noted the 
enrollee was in no acute distress or shortness of breath at the time of saturation levels in the 80's. Oxygen at 2 
liters resolved these saturations and while the enrollee was discharged on the low flow oxygen in the setting of 
chronic obstructive pulmonary disease (COPD) with a past history of possible issues with saturations post 
operatively, the enrollee was also described consistently to be in no acute distress, with no increased respiratory 
effort or work of breathing, and it is unclear this is unexpected in the setting of this enrollee's comorbidities. An 
arterial blood gas measurement was not found during the encounter. The review indicates that DRG 469 was 
not supported by the provided records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from April 19, 2021 to April 23, 2021 billed with DRG 469.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 7, 18, and 19. 
 
You asked the Plan to pre-approve the crowns. You say that half a tooth broke off while you were eating, and 
you would like something to be done for you. The Plan denied your request. The Plan says that the updated 
dentist notes do not show these crowns on the treatment plan, and cannot be approved. 
 
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 did not provide a copy of the full dental benefits for the 2021 and 2022 
Plan years for this case. The Plan also did not provide the Notice of Denial of Medicare Coverage (NDMC) for 
these services. We asked for these documents, but they were not provided to us. Without this information we 
cannot determine that the Plan's coverage rules support the denial of approval in this case, or that the enrollee 
has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not 
substantiated their denial of approval in this case. Therefore, we decided that the Plan has to pre-approve 
crowns (D2740) for tooth #'s 7, 18, and 19.  
 
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.