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

 
We decided that the Plan does not have to pay for the medication services provided on August 17, 2021. 
 
You asked the Plan to pay for the billed services. You say that the medications were shipped in good faith. The 
Plan denied your request. The Plan says the documentation did not include an itemized invoice or proof of 
delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the medications were dispensed by a pharmacy and shipped to the 
enrollee. Since the medication does not represent an expense to the physician and will not be included in the 
physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay 
for the medication services provided on August 17, 2021.  
 
 
 Benefits for the billed services 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional computed tomography scan of the lumbar spine 
(72131) provided on October 4, 2021. 
 
You asked the Plan to pay for an additional computed tomography scan. You say that this is supported in the 
records. The Plan denied your request. The Plan says this was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 72131 are not supported in the medical record. The medical record 
only supports one unit of CPT code 72131, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an additional computed tomography scan have not been met. 
Therefore, we decided that the Plan does not have to pay for an additional computed tomography scan of the 
lumbar spine (72131) provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 23, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing that 
should be covered. The Plan denied your request. The Plan says this panel should be billed with a single CPT 
code. As such, only 11 of the 13 billed codes are payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. This next-generation sequencing panel was billed with multiple codes 
instead of the single panel code as required. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing as billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on August 23, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lower partial denture provided on June 23, 2021. 
 
You asked the Plan to reimburse you for the dental item. You say that you understood that the appliance would 
not be covered. You say that you feel that the dental appliance did not function as you feel it should have. You 
also say that you feel you should not be responsible. The Plan denied your request. The Plan says the partial 
lower denture is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Additionally, the record shows that you signed an agreement acknowledging 
financial responsibility for the lower partial denture. Therefore, we decided that the Plan does not have to 
reimburse you for the lower partial denture provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 30, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. 
 Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services, and the self-administered drug 
provided in an outpatient setting on December 13, 2021. 
 
You asked the Plan to pay for the emergency services and self-administered drug. You say that you did not 
receive a denial yet. You say that this scares you. You also say that you want to get things moving on them. 
The Plan denied your request. The Plan says the claim processed 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 $120 
copayment for Emergency care.  
 
You have been asked to pay a $120 copayment for the emergency services. The emergency services fall 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. Additionally, the drug you received while in the emergency room is considered self-administered. 
Self-administered drugs are not covered under Medicare Part B. Therefore, we decided that the Plan does not 
have to pay for the emergency room services, and the self-administered drug provided in an outpatient setting 
on December 13, 2021.  
 
Benefits for the emergency services and self-administered drug 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 the filling (D2394), adjunctive prediagnostic test (D0431), 
scaling and root planing (D4342 x 2), and gingival irrigation (D4921 x 2) provided on August 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
fillings were covered. You say that only after the work was completed was it discovered that some of it would 
not be covered. You also say that the work was performed based on false information provided by your plan. 
The Plan denied your request. The Plan says there are limited dental benefits covered in 2021. The Plan says 
the services you received are not listed as covered. The Plan also says that you were not enrolled in the optional 
supplemental dental rider. 
 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 filling, scaling and root planing, 
gingival irrigation, and adjunctive prediagnostic test are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the filling (D2394), adjunctive prediagnostic test (D0431), 
scaling and root planing (D4342 x 2), and gingival irrigation (D4921 x 2) provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) and five additional intraoral periapical x-rays (D0230 x5) provided on March 9, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images and additional intraoral periapical x-rays. 
You say that the dentist did not advise you that they were performing services that were not covered under your 
dental plan. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered 
expense under your dental plan. The Plan also says that your benefits for intraoral x-rays have been satisfied 
and the frequency limitation 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, 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on March 9, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4) and five 
additional intraoral periapical x-rays (D0230 x5) provided on March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you have complete coverage for this service. 
You say that you did not want to go to the hospital as they are full of coronavirus. You say that you did not 
want further problems. You also say that this claim should be changed to $0. The Plan denied your request. The 
Plan says as no transport occurred, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 10, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
  
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus immunization (90715), provided on November 
15, 2021. 
 
You asked the Plan to pay for the immunization. You say that the service should be covered. The Plan denied 
your request. The Plan says you received this vaccine as a preventative measure. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus immunization (90715), provided on 
November 15, 2021.  
 
Benefits for the immunization 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 the full mouth debridement to enable a comprehensive 
evaluation and diagnosis on a subsequent visit (D4355) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were advised you were having a cleaning. 
You say that they did not advise it was a full mouth debridement. You also say that you would like this to be 
covered. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 full mouth debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement to enable a comprehensive evaluation and diagnosis on a subsequent visit (D4355) 
provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on July 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code 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. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate 
the presence of an independent trained observer. 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 the 
sedation services provided on July 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on February 8, 2021. 
 
You asked the Plan to pay for the coronavirus test. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two adjunctive procedures (D9999 x2) provided on 
November 22, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the adjunctive procedures. You say that you were not advised that this dentist 
had opted out of Medicare. You also say that you were told to pay the dentist and you would be reimbursed. 
The Plan denied your request. The Plan says you received these services from a provider who chose not to 
receive Medicare funds. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the two adjunctive procedures (D9999 x2) provided on November 22, 2021 by a 
Medicare opt out provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services, provided on October 6, 2021 to 
January 20, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization is required for non-emergent services obtained through 
an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the mental health services, provided on October 6, 
2021 to January 20, 2022 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced care planning, 30 minutes, (99497) and hospital
discharge day management (99239) provided from April 21, 2021, to April 22, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request.
The Plan says while a portion of this claim was paid, the remainder of the services billed fall under the
enrollee's hospice dates and should be submitted to Original Medicare first. Maximus partially overturned the
Plans denial as proof of payment of some of the services billed had not been included in the case file. The Plan
requested a reopen and provided the required payment information. The Plan provided documentation to show
they reprocessed the claim for date of serviced April 21, 2021, for code 99497 which was paid on October 5,
2021 in the amount of $81.53. Payment was issued within the total check amount of $1753.16.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the remainder of this claim must be submitted to Original Medicare for
review. Therefore, we decided that the Plan does not have to pay for the advanced care planning, 30 minutes,
(99497) and hospital discharge day management (99239) provided from April 21, 2021, to April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 18, 2021.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Tempus Gene
Panel testing. The Maximus Physician Reviewer determined that the testing provided in this case meets criteria
and is medically reasonable and necessary. The Plan requested a reopen and states alternative tests to identify
targeted therapy for pancreatic cancer were not performed. The Plan also states that Tempus gene testing is not
supported by published literature and Tempus gene has not been FDA-approved, and there is no documentation
of analytical validity and clinical utility. Finally, the Plan states Tempus gene is a panel of over 648 genes,
which is more than the number of reasonable and necessary genes required for therapeutic decision-making.
The enrollee is a 68-year-old woman with a diagnosis of metastatic pancreatic cancer. The clinical records in
the case file are limited. The Plan is correct in this case. The documentation in the case file does not support
that the Tempus Gene Panel testing in this case met all of the LCD coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not
have to pay for genetic testing provided to the enrollee on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, SNF services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined that while there were not documented skilled nursing needs,
there were documented skilled therapy needs. The Plan requested a reopen and argues that the records show
you were cleared medically and able to walk household distances, which was within previous baseline function.
There were no services required that could only be provided on an inpatient only basis, which is one of the
criteria for admission to a skilled nursing facility. In addition, you were evaluated by and participated in
occupational and physical therapies in the acute hospital, where a maintenance program was developed. These
recommendations for further therapy could be provided at an alternate level of care. The Plan is correct in this
case. The documentation does not support that it was medically reasonable and necessary to provide you with
skilled services on a "daily basis" on an inpatient basis in a skilled nursing facility setting. Medicare coverage
criteria were not met.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.