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

 
We decided that the Plan does not have to pay for the new patient office visit billed for services provided on 
Jun 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seeing different doctors with 
different specialties. The Plan denied your request. The Plan says an established patient code should have been 
used. 
 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 99204 is not supported. The enrollee was seen by the same physician group with 
providers of the same specialty, internal medicine with a cardiac focus. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the new patient office visit billed for services provided on Jun 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim was underpaid. The Plan denied your 
request. The Plan says the results are not clearly aligned with the procedure code. 
 
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. The testing described by billed code 83789 is considered specimen 
validity testing which is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on June 22, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee must receive care from a 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 ophthalmological services 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 ophthalmological services these items/services. Therefore, we decided that the Plan does not have to pay for ophthalmological services 
provided on June 22, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental cleaning (D1110) and the periodic oral evaluation (D0120)
provided on March 8, 2022.
You asked the Plan to pay for the dental cleaning and the periodic oral evaluation. You say that you are
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that
your benefit for the requested item or service has already been exhausted.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There is no evidence showing your benefit for the requested item or service was
previously exhausted. The Plan has now provided the necessary 2022 Evidence of Coverage documentation to
show that these services are covered twice every 12 months. However, documentation is still lacking regarding
proof these services have already been covered twice within the 12 months prior to these services being
received. Therefore, we decided that the Plan has to pay for the dental cleaning (D1110) and the periodic oral
evaluation (D0120) provided on March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy provided May 27, 2022, to May 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home infusion therapy. You say that it was necessary to render these services. 
The Plan denied your request. The Plan says the enrollee must get care from network providers. 
 
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 home infusion therapy 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 supplies these items/services. Therefore, we decided that the Plan does not have to pay for home infusion therapy provided 
from May 27, 2022, to May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve repeat ESI. You say that the ESI is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has experienced 3 months of at least 50% pain relief from the initial injection. 
Therefore, the reviewer found that a repeat ESI is 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planning (D4341) provided on July 28, 
2022, August 1, 2022, and August 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service provided should be covered by 
the Plan. The Plan denied your request. The Plan says the denial of payments for this service is correct, because 
scaling and root planning is not covered by the 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 the 
scaling and root planning (D4341) provided on July 28, 2022, August 1, 2022, and August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of upper 
extremity, any joint (73221RT). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee completed a 6 to 12-week trial of physical therapy for their shoulder pain. Therefore, 
the reviewer found that the requested MRI is not medically necessary at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of upper extremity, any joint (73221RT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to this claim as billed.
You asked the Plan to pay this claim as billed. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met. Maximus partially overturned the
Plans denial. The Plan requested a reopen and stated that codes 99285 and 93010 were denied no records. The
required records have been received and these codes are not in reopen review.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. Code 99053 has a status
indicator of B on the Physician Fee Schedule. This means that CPT code 99053 is not separately payable.
Codes 99285 and 93010 are under review at the Plan level. Therefore, we decided that the Plan does not have
to pay this claim as billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #27 (D2332) and a 
resin-based composite filling on tooth #28 (D2391) provided on May 24, 2021, prophylaxis (D1110) provided 
on November 23, 2021, and a prefabricated steel crown on tooth #31 (D2931) provided on December 9, 2021. 
 You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the benefit for fillings and a cleaning has already been exhausted. 
The Plan also says that a prefabricated steel crown is not a covered service. 
 
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 the benefit for fillings was exhausted on date of service December 9, 2021. The record also shows the 
benefit for a cleaning was exhausted on date of service May 10, 2021. Therefore, we decided that the Plan does 
not have to pay for a resin-based composite filling on tooth #27 (D2332) and a resin-based composite filling on 
tooth #28 (D2391) provided on May 24, 2021, prophylaxis (D1110) provided on November 23, 2021, and a 
prefabricated steel crown on tooth #31 (D2931) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of denial services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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 the requested item or service was exhausted on date of service July 28, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 9, 2022. 
 
You asked the Plan to pay for the intraoral x-ray. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an 
intraoral x-ray (D0210) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0140), radiographic images 
(D0210), and a full mouth debridement (D4355) provided on June 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the dental services would be 
fully covered. The Plan denied your request. The Plan says the claim was reprocessed at an in-network benefit 
level and the proper coinsurance was charged for the class 2 basic services that were rendered. 
 
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. 
 
  You have been asked to pay $158 coinsurance for the dental procedures. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to pay more for an oral evaluation (D0140), radiographic images (D0210), and a full mouth debridement 
(D4355) provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Comprehensive Oral Evaluation (D0150) provided on May 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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 the requested item or service was exhausted on date of service May 17, 2022. Therefore, 
we decided that the Plan does not have to pay for a Comprehensive Oral Evaluation (D0150) provided on May 
17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on May 23, 2022. 
 
You asked the Plan to pay for the core buildup services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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, 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 core 
buildup services (D2950) provided on May 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for five physical therapy visits for the enrollee.
You asked the Plan to provide coverage for ten physical therapy visits. The Plan denied your request. The Plan
says while five visits were approved, the enrollee does not meet criteria for the ten visits requested. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy. The enrollee has a diagnosis of Parkinson's disease. Physical therapy is
intended to restore the enrollee to a previous level for function or on a limited basis to attempt to prevent
deterioration of the enrollee's condition. The Plan approved five of the ten visits requested to accomplish a
maintenance program for the enrollee. The remaining five visits exceeded the enrollee's needs based on there
being no expectation of the enrollee returning to a prior level of function with the given diagnosis. Therefore,
we decided that the Plan does not have to provide coverage for the remaining five visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (code 64450) provided to the enrollee on
December 10, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and demonstrated that the injection services provided on December 10,
2021, were not performed bilaterally. The provider did not bill modifier 59 (Distinct Procedural Service).
Modifier 50 (Bilateral Procedure) was billed with code 64450. Due to the medical records documenting that the
procedure was performed on the right side and not bilaterally, the claim is not supported as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and when required the
appropriate modifiers. In this case, this claim cannot be paid as billed due to an error with the reported
modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan
does not have to pay for physician services (code 64450) provided to the enrollee on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services (93005) provided to the enrollee on
December 17, 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 Medicare billing criteria were not met due to the bundled codes rules. Maximus
overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and stated
that according to Medicare Claims Processing Manual, Chapter 4, Section 10.4, status indicator Q1 is assigned
to STV packaged services. STV-packaged services are services for which separate payment is made only if
there is no service with status indicator S, T, or V reported on the same claim. CPT code 93005 were
reported on the same claim with CPT codes containing status indicator S (CPT codes 71275, 74174,
93306, and G0463). CPT codes with status indicator S were paid. Therefore, no separate payment is
required for CPT code 93005. Maximus stated that the Plan has not made reasonable and diligent efforts to
gather and forward the information regarding the Plan's decision to deny the provider's request. While the
denial rationale the Plan provided only mentioned CPT code 93005 was being denied because it is assigned
status indicator N (Items and Services Packaged into APC rates), the pricing sheet was submitted to
Maximus. The pricing sheet contained details which include status indicators and payment amount.
The Plan initially paid $1,300.46 on January 12, 2022, at 100% Medicare APC (Ambulatory Payment
Classifications) rate. An additional payment of $173.05 was made on January 26, 2022. Proof of payments
were submitted.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes.
In this case, this claim could not be paid as billed due to the bundled relationships between the codes submitted.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for diagnostic services (93005) provided to the enrollee on December 17, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 20, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing meets the criteria. The Plan denied 
your request. The Plan says that the testing is not a Medicare benefit. 
 
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. 
 
This testing was provided to a patient with a solid tumor. The FDA approval notice indicates that this panel is 
approved for solid tumors. 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 pay for 
the laboratory services provided on January 20, 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.