Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 8, 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 the provider did not bill as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93880 is a column II code to column I code 76536. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services and electrocardiogram (ECG) testing provided on August 14, 2021, billed with primary diagnosis code R65.10.
You asked the Plan to pay for the services as billed. You say that this was billed correctly and was medically necessary. The Plan denied your request. The Plan says the claim was billed with a diagnosis that is inappropriate for a primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM guidelines must be followed for billing. The guidelines indicate that codes with a "Code first" note are manifestation codes and should be coded after the etiology code. Diagnosis code R65.10 has a Code first note in the ICD-10-CM Codebook. It is noted that the underlying condition such as heatstroke or an injury/trauma should be coded prior. As this was used as the primary diagnosis code, we find that Medicare billing rules have not been met for this claim. Therefore, we decided that the Plan does not have to pay for the critical care services and electrocardiogram (ECG) testing provided on August 14, 2021, billed with primary diagnosis code R65.10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of these dental services.
You asked the Plan to pay for dental services. You say that these dental services should be covered by the Plan.
The Plan denied your request. The Plan says the dental services provided are not covered under the Plan
benefit. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus
did not apply the correct contract language.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan
offers a dental benefit in excess of Medicare coverage, the codes billed are not among those listed in the Plan
contract as a covered benefit. Therefore, we decided that the Plan does not have to pay for dental services
provided on April 22, 2021, coded as (D1330), (D4341, D4342), (D4999), (D9215), and (D9430).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on September 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (71045) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide further reimbursement for these vision services.
You believe the Plan should pay more of the cost of these vision services. The Plan denied your request. The
Plan says the $200 benefit was applied; the remaining charges are those costs incurred over the $200 benefit
submitted by your vision provider. Maximus partially overturned the Plans denial. The Plan requested a reopen
and provided additional information. The Plan states that supplemental annual eyewear allowance applies to the
retail value only. Taxes are not covered and unused balances from the previous contract year do not carry over.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services.
However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason,
the Plan's coverage rules apply in this case. The Plan covers only covers vision costs up to $200.
Any costs over the $200 maximum, including tax, is your financial responsibility. The Plan has no control over
the costs the retail vision provider applies to their retail products. The Plan is not required to give you discounts
to these products above the $200 allowance. The Plan is not able to waive or pay for state or retail taxes on
vision items. Therefore, we decided that the Plan does not have to pay for the bifocal lenes, anti-reflective
coating and frames provided on May 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the group psychotherapy (CPT code 90853) provided on July 12, 2021, by a LMHC.
You asked the Plan to pay for the services. You say that you have post-traumatic stress disorder (PTSD) which can turn into schizophrenia very easily and you saw the out-of-network provider because you get suicidal. The Plan denied your request. The Plan says although there is documentation you were referred to this mental health counselor by a contracted provider, you were informed via the evidence of coverage (EOC), prior to services ever being rendered, the services provided by a mental health counselor are not covered by your plan. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This service is not covered as the provider is a mental health counselor and not eligible for payment by the health plan or original Medicare. Therefore, we decided that the Plan does not have to pay for the group psychotherapy (CPT code 90853) provided on July 12, 2021, by a LMHC.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services received on April 6,
2021.
You asked the Plan to waive the copayment for the services. You say that this should be waived. The Plan
denied your request. The Plan says the copayment was applied 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 $275
copayment for ambulance services.
You have been asked to pay a $275 copayment for the services. The services fall within the ambulance 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.
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services received on
April 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (CPT code(s): A0428 and A0425) provided to the enrollee on July 3, 2021.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Review of the claim history indicates the enrollee was in inpatient hospital status on this date of service (June 16. 2021). The referring claim indicating this enrollee was inpatient and shows admit date of July 2, 2021, and discharge date July 13, 2021. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example are considered part of the inpatient admission and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (CPT code(s): A0428 and A0425) provided to the enrollee on July 3, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 25, 2022.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the clinical documentation does not show with clear evidence that the enrollee has any ongoing skilled needs.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 25, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 25, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 lab services provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on April 27, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 office visit (CPT code 99213) provided to the enrollee on April 27, 2021, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on September 22, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you feel that the denial of these services is unreasonable and should be reconsidered for coverage. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal exam and comprehensive oral evaluation share a frequency limitation of one procedure code every three years, and full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a periodontal exam (D0180) and full mouth x-rays (D0210) on February 26, 2019 and your periodontal exam and comprehensive oral evaluation benefit and full mouth or panoramic x-rays benefit have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on September 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90838) rendered by the out-of-network
(OON) provider on September 20, 2021.
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 psychotherapy (90838) rendered by the out-of-network (OON) provider on
September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 1, 2021.
You asked the Plan to pay for the prophylaxis. You say that because you had throat cancer it was recommended that you have dental cleanings three times per year instead of the normal two times per year. The Plan denied your request. The Plan says prophylaxes (cleanings) are payable twice per calendar year.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, cleanings are limited to twice per year. The record shows that you received cleanings on January 21, 2021, and May 28, 2021 and your cleanings benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular assessment testing provided on August 31, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this was non-covered screening testing.
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. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular assessment testing provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites - one surface, posterior (D2391) provided September 30, 2021.
You asked the Plan to pay for the two fillings. You say that you were not aware that the provider had done more than your 2 covered of fillings on this date of service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 two fillings per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that 2 fillings were covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of fillings has been exceeded and the two additional fillings are not covered. Therefore, we decided that the Plan does not have to pay for the two resin-based composites - one surface, posterior (D2391) provided September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 15, 2021.
You asked the Plan to waive the copayment the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing 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 $35 copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $35 copayment for a specialist office visit. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits 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 specialist office visit provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for hearing aids provided on
June 15, 2021.
You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan says the health Plan applied the $500 hearing aid benefit to your claim, the total amount of the claim was $2888.00 ($2888.00 - $500 (hearing aid benefit) = $2388.00 member responsibility. The remaining amount of $2388.00 is your responsibility.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to $500 for a hearing aid once every 3 years. We looked at the file and the Plan's rules. The file shows that the health Plan applied the $500 hearing aid benefit to your claim and the remaining amount of $2388.00 is your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on June 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (S9122) provided from June 7,
2021, to June 28, 2021, and August 9, 2021, to August 25, 2021.
You asked the Plan to pay for the home health services. You say that the providers in this case have not opted
out of Medicare. The Plan denied your request. The Plan says payment cannot be made for services received
from providers who are not certified by 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 providers at issue are not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home health services (S9122)
provided from June 7, 2021, to June 28, 2021, and August 9, 2021, to August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from June 20, 2020, to June 23, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these should be covered. The Plan
denied your request. The Plan says the drugs you received are considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs
you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided in an outpatient setting from June 20, 2020, to June 23, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights