Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says that the remaining 14 physical therapy visits are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there are no stated goals or complications in which the 
professional assessment and treatment by a physical therapist would be needed thus 14 additional physical 
therapy sessions are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 14 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mechanical traction therapy (97012) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that there is no clinic in your area within the 
Plans network. You say you were previously approved for services with the requested provider. The Plan 
denied your request. The Plan says you must follow in-network referral guidelines for health plan covered 
services. Furthermore, the Plan says authorization must be obtained for future services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
mechanical traction therapy (97012) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the deductible for podiatry services provided from September 8, 2021, and December 15, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says the deductible applies to podiatry services per the Plan contract. Maximus 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. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $35 copay per visit which applies to after the deductible has been met for podiatry services.
The records show these were podiatry visits for the treatment of toenail debridement. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $35 copayment per visit which applies podiatry services after the deductible has been met. The records also show the deductible had not been met at the time of service. Therefore, we decided that the Plan does not have to waive the cost share applied to the deductible for podiatry services provided from September 8, 2021, and December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
March 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of 
intraoral x-rays (D0210), two occlusal guards (D9944 x2), and four resin-based composites (D2330 x4) 
provided from October 29, 2021, to December 16, 2021, by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, occlusal guards, 
and resin-based composites. You say that you were unaware that you had to use a Medicare approved dentist. 
You also say that you would like to be reimbursed for these services. The Plan denied your request. The Plan 
says these services were performed by a provider who has opted out of Medicare. The Plan also says that the 
treating provider opted out of Medicare effective July 22, 2021, to July 22, 2023. 
 
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 rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), 
two occlusal guards (D9944 x2), and four resin-based composites (D2330 x4) provided from October 29, 2021, 
to December 16, 2021, by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5110 and D5120). 
 
You asked the Plan to pre-approve the dental services (D5110 and D5120).. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 
are not covered benefits. 
 
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 pre-approve the 
dental services (D5110 and D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on December 
21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment can be made for these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83789 billed for date of service March 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says validity testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for code 83789 billed for date of service March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bitewing - single radiographic image (D0270) provided on 
May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services were covered by the 
Plan. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a bitewing - single radiographic image (D0270) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam filling on tooth #30 (D2150) and pin retention 
on tooth #30 (D2951) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a filling on a different part of this 
tooth. The Plan denied your request. The Plan says your benefit for an amalgam filling has already been 
exhausted. The Plan also says that pin retention (D2951) is not covered by your dental benefits. 
 
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 an amalgam filling was exhausted on date of service January 13, 2022. Pin retention is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
amalgam filling on tooth #30 (D2150) and pin retention on tooth #30 (D2951) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120), radiographic images (D0220 and 
D0274), and prophylaxis (D1110) for tooth #8 and #25 provided by an out-of-network (OON) provider on June 
16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the claim to be processed as an 
in-network provider. The Plan denied your request. The Plan says the dental services were received from an 
OON provider and are not covered by the enrollee's supplemental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows the enrollee received the requested dental services from an OON provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for 
an oral evaluation (D0120), radiographic images (D0220 and D0274), and prophylaxis (D1110) for tooth #8 
and #25 provided by an out-of-network (OON) provider on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth, or exposed root (elevation and/or 
forceps removal) (D7140) provided on May 5, 2022. 
 
You asked the Plan to pay for extraction, erupted tooth, or exposed root (elevation and/or forceps removal) 
(D7140). You say that your Plan sent you to this dentist so you should not have to pay. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
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 
extraction, erupted tooth, or exposed root (elevation and/or forceps removal) (D7140) provided on May 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits from May 12, 2022, to 
June 14, 2022. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you should not have to pay a 
copayment for each visit. You also say that you have visits twice a week and cannot afford to pay this. The 
Plan denied your request. The Plan says the cost share has been 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 $15 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
 
 You have been asked to pay $195 ($15/visit x 13 visits) for specialist visits. Specialist visits fall within the 
consultation, diagnosis, and treatment by a specialist 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 
copayments for specialist visits from May 12, 2022, to June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar tooth on June 2, 2022. 
 
You asked the Plan to pay for endodontic therapy, molar tooth. You say that you would like to request 
reconsideration of the denied claim and that you were in-network. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 
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 
endodontic therapy, molar tooth on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware the provider was OON. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and an unspecified 
removable prosthodontic procedure (D5899) provided on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous dentures did not fit properly so 
you went somewhere else. The Plan denied your request. The Plan says your benefit for a complete maxillary 
denture has already been exhausted. The Plan also says that an unspecified removable prosthodontic procedure 
(D5899) is not covered by your supplemental dental benefits. 
 
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 a complete maxillary denture was exhausted on date of service March 5, 2020. An 
unspecified removable prosthodontic procedure (D5899) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and an 
unspecified removable prosthodontic procedure (D5899) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on 
November 19, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 CPT code 99221 is not supported in the medical record. Specifically, the documentation shows 
that surgery procedure 36556 (insertion of non-tunneled centrally inserted central venous catheter) was 
provided on the same date of service, by a provider with the same Tax ID and same specialty. This code is 
included in the surgical procedure when billed on the same date. This means code 99221 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services 
coded 99221 provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00811) provided on October 11, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed 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. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 00811 is not supported in the medical record. Specifically, 17 units of this service were 
billed. Records show that the enrollee was under anesthesia for 23 minutes for a colonoscopy. Additional 
minutes of anesthesia are not supported in the documentation provided. Based on this information, we decided 
that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (00811) provided on October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) physical therapy (PT) visits to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that during this year, you have had multiple visits to 
different PT offices. You used to live near the requested facility and the treatment provided was very effective. 
You would like to return to that facility. The Plan denied your request. The Plan says you must use network 
providers to get health care and services when there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
twelve (12) physical therapy (PT) visits to be provided by an out-of-network (OON) provider.