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

 
We decided that the Plan has to reimburse you for the acupuncture services provided on June 1, 2020. 
 
You asked the Plan to reimburse you for the services provided. You say that the services are helpful in your 
continuing treatment. The Plan denied your request.  
 
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 file shows that you received acupuncture services to treat low back pain. There is no documentation to 
show that you were previously reimbursed for these services by the Plan. There is no documentation that shows 
you met Medicare benefit limits prior to the date of service at issue. The Plan notes a $65 copay for covered 
acupuncture services. However, the Evidence of Coverage does not show there is a copay for Medicare-
covered acupuncture services. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to 
reimburse you for the acupuncture services provided on June 1, 2020.  
 
 
 
 
 
 
 
 
 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747). 
 
You asked the Plan to pre-approve the bone growth stimulator. You say that the device is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that bone growth stimulators are covered for a spinal or 
long bone fracture. 
 
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 bone growth stimulator. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found the enrollee 
has a non-displaced 3rd metatarsal right foot fracture. This is not a spinal or long bone fracture, and imaging 
shows only 3 months of non-union. 
 
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 bone growth stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone growth stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on November 9, 
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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on November 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the individual psychotherapy services (90832) provided August 17, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that  The Plan denied your request. The 
Plan says that a referral form or reference to a copy of the report available to a physician does not satisfy the 
documentation criteria. 
 
The Plan must follow Medicare rules. The rules say if the patient consents, you must attempt to consult their 
attending or primary care physician about provided services and either document consent or declination date to 
consultations and date of consultations in patients medical record. 
 
We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at 
issue. Documentation of a physician consultation does not apply when the physician has referred the 
beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage 
of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the individual 
psychotherapy services (90832) provided August 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and resin-based filling (D2335) 
provided on October 25, 2021. 
 
You asked the Plan to pay for the intraoral x-ray and resin filling. You say that you saw that your dental plan 
changed when you got your new ID cards, and you saw that these services would be covered with your new 
plan. The Plan denied your request. The Plan says these services were not covered by your 2021 dental benefit. 
The Plan also says they do not have any record of you contacting the plan prior to services to verify your 
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 pay for the 
intraoral x-ray (D0220) and resin-based filling (D2335) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional practice expenses incurred during a Public Health 
Emergency (PHE), including supplies and additional clinical staff time (99072) provided September 7, 2021. 
 
You asked the Plan to pay for the additional services. You say that you are appealing non payment of CPT 
codes 99072, 98943, 97012 and G0283. Please see attached EOB from different date of service with the exact 
CPT codes and they were paid. Please reprocess the claim for payment. The Plan denied your request. The Plan 
says service is considered incidental to the enrollee's total episode of care. 
 
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 99072 
is a column II code to column I code 98941. 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 additional practice expenses incurred during a Public Health 
Emergency (PHE), including supplies and additional clinical staff time (99072) provided September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on November 4, 2021. 
 
You asked the Plan to pay for the intraoral x-ray. You say that you cannot determine one type of x-ray from 
another, and you feel you should not be responsible for this cost. The Plan denied your request. The Plan says 
this type of x-ray is 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. 
 
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 the 
intraoral x-ray (D0220) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom abutment (D6057) and implant supported crown 
(D6065) provided on October 12, 2021 
 
You asked the Plan to pay for the dental services. You say that you were under the impression these services 
were covered and you did not expect this bill. The Plan denied your request. The Plan says these 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom abutment (D6057) and implant supported crown (D6065) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reduction of osseous tubersity (D7485), and an incision and 
drainage of abscess (D7510) provided by a participating provider on September 3, 2021. 
 
You asked the Plan to pay for a reduction of osseous tubersity and an incision and drainage of abscess. You say 
that you did not know what the doctor would find. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the dental services that were provided 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 Plan's 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 a 
reduction of osseous tubersity (D7485), and an incision and drainage of abscess (D7510) provided by a 
participating provider on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), topical application of 
fluoride excluding varnish (D1208), and periodontal maintenance (D4910) provided on October 1, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation, topical application of fluoride excluding varnish, 
and periodontal maintenance. You say that the dental office submitted the charges more than once and also 
spoke with a Plan representative by phone. The Plan denied your request. The Plan says you have already 
received the maximum amount of coverage allowed 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan pays up to $2,000 every year 
for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services 
combined. The contract says that you are responsible for any amount above the dental coverage limit. The 
record shows that you met the annual maximum benefit on March 25, 2021 and your annual maximum benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120), topical application of fluoride excluding varnish (D1208), and periodontal maintenance (D4910) 
provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9945) provided on October 27, 2021. 
 
You asked the Plan to pay for the dental item. You say that the occlusal guard is to help stabilize your upper 
teeth so that you may keep them as long as possible. The Plan denied your request. The Plan says occlusal 
guard is not a covered item. 
 
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, the occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard 
(D9945) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the extraction (D7210) and bone 
replacement graft (D7953) provided on September 30, 2021, provided by the out of network provider. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you were told the dentist 
was in network. You say that the service was paid at 50% of the allowed amount instead of the in network 
level. You say that the dentist was out of network at the location you received services. You also say that the 
provider is a travel specialist and does not have one set location. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out of network providers may bill you 
for any amount greater than the plan pays. Additionally, the record shows that the plan did not give any 
misinformation. Therefore, we decided that the Plan does not have to pay the in network rate for the extraction 
(D7210) and bone replacement graft (D7953) provided on September 30, 2021, provided by the out of network 
provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 22, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to your doctor's office and were sent to the emergency room because your blood pressure was high. You also say that the emergency room doctor should have done an electrocardiogram due to your medical history. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $90 copayment for in-network emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 22, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service October 
4, 2021. 
 You asked the Plan to pay for procedure code 76705-26. You say that you have provided medical records to 
support payment for this code. The Plan denied your request. The Plan says payment for this code is bundled 
into payment for code 93976. 
 
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 
76705-26 is a column II code to column I code 93976. 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 procedure code 76705-26 billed for date of service 
October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99135 and 00320 provided on May 20, 
2021. 
 
You asked the Plan to pay for procedure codes 99135 and 00320. You say that these services should be covered 
as in-network. The Plan denied your request. The Plan says payment for code 99135 if bundled into payment 
for other codes on the same date.  The Plan also says that code 00320 is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that for procedure codes with a status indicator of B 
on the Medicare Physician Fee Schedule Database, payment for these services is always bundled into payment 
for other services.  No separate payment is ever made for these codes. Procedure code 99135 has a status 
indicator of B on the Medicare Physician Fee Schedule Database, so this code is not separately payable.   
In relation to code 00320, 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 procedure 
code 00320 is anesthesia procedures on the esophagus, thyroid, larynx, trachea, and lymphatic system. 
 
We find that CPT code 00320 is not supported in the medical record. Specifically, no procedure related to the 
esophagus, thyroid, larynx, trachea, or lymphatic system is noted in the record. The only procedure 
documented in the medical record is an anterior cervical discectomy and fusion procedure at spine levels C4-
C7.  Separate anesthesia services were billed for this procedure. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99135 and 00320 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99135 and 00320 provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950), and a crown (D2750) provided by 
Contemporary Dental Arts on November 2, 2021. 
 
You asked the Plan to pay for a core build-up and a crown. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the services that were provided 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 Plan's 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 a core 
build-up (D2950), and a crown (D2750) provided by Contemporary Dental Arts on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implants (D6010) provided on March 6, 2021. 
 
You asked the Plan to pay for the dental implants. You say that you were told you had $2,000 coverage for 
dental care. The Plan denied your request. The Plan says this service is 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 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 the dental 
implants (D6010) provided on March 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is approved for an anterior 
cervical discectomy and fusion (ACDF). There is no specific indication provided to support the request for 
bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the 
planned cervical spine surgery.  There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow 
aspirate is not medically reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.