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

 We decided that the Plan does not have to pay for the mass spectrometry rendered on March 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services 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. In this case, we have confirmed that code 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. There is no documentation to support the -59 modifier as a separate and distinct procedural 
service. 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 mass spectrometry rendered on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bridge (retainer crown) for teeth 6 and 9 and a 
replacement tooth (pontic) for teeth 7 and 8. 
 
You asked the Plan to pre-approve these services. You say that you were told that the services were covered. 
The Plan denied your request. The Plan says the services are not covered. 
 
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 a 
bridge (retainer crown) for teeth 6 and 9 and a replacement tooth (pontic) for teeth 7 and 8.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services
provided from August 18, 2021, to August 20, 2021.
You asked the Plan to waive this cost share. You say that you were admitted to the hospital and this copayment
should waived. The Plan denied your request. The Plan says the records show you were not put into inpatient
status while you were in the facility. Maximus overturned the Plans denial. The Plan requested a reopen
provided additional claim information.
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan
clearly says that you must pay $90 copayment for emergency room services.
The medical records and the claim submitted by the provider indicate at no time was the stay considered an
"inpatient" visit. 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 $90 copayment charged for emergency room services provided from
August 18, 2021, to August 20, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve seven (7) speech therapy (ST) visits. 
 
You asked the Plan to pre-approve ST visits. You say that the requested ST visits are medically necessary. The 
Plan denied your request. The Plan says that the requested ST visits do not meet criteria. 
 
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 ST visits. Our reviewer says that the 
service is medically necessary. Our physician reviewer found per clinical documentation, the enrollee has poor 
PO intake on honey thickened liquids and puree textures placing her at a high risk for aspiration pneumonia. 
Speech therapy is an accepted treatment for dysphagia and clinical case would generally require the skill of a 
professional therapist both for advancement and safety from complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ST visits have been met. Therefore, we decided that the Plan has to pre-approve 
seven (7) speech therapy (ST) visits.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Dronabinol capsule. 
 
You asked the Plan to pre-approve Dronabinol. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B when prescribed in the enrollee's clinical situation. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Dronabinol capsule.  
 
Benefits for Dronabinol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 15, 
2021. 
 You asked the Plan to pay for procedure code 99100. You say that these services were billed appropriately. The 
Plan denied your request. The Plan says separate payment for this code is not available. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Therefore, we decided that the Plan does not have to pay for procedure 
code 99100 billed for date of service October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three crowns (D2740 x3) and three core buildups, 
including any pins when required (D2950 x3) provided on December 2, 2021. 
 
You asked the Plan to pay for the crowns and core buildups. The Plan denied your request. The Plan says these 
dental services are not covered by your medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the three crowns (D2740 x3) and 
three core buildups, including any pins when required (D2950 x3) provided on December 2, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on March
24, 2021, under code 99218.
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 this code cannot be separately paid when code 99221 is billed. Maximus overturned the
Plans denial for lack of proof of payment of code 99221. The Plan requested a reopen and provided proof of
payment for code 99221.
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 code. In this case, a NCCI code
pair edit exists between codes 99218 and 99221. The new documentation shows code 99221 was previously
paid. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for emergency room services provided to the enrollee on March 24, 2021, under code 99218.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to waive or reduce the cost-share assessed April 29, 2021, and May 06,
2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was applied based on the services provided and the
Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and
stated that Maximus did not apply the correct contract calculations. The Plan demonstrated that the Medicare
Allowable for this injection, Q0158 was $1,477.08 and 20% coinsurance would be $295.42. This would be
applied for each date of service. The Medicare allowable for administration, or code 258, was $10.80 and 20%
coinsurance would be $2.16, which was also applied for each date of service.
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 (such as copayments, deductibles, and coinsurance). Your contract with the Plan
clearly says that you must pay a 20% coinsurance for Medicare Part B drugs and administration. The procedure
codes Q0138 and 258 for both dates of service April 29 & May 06, 2021, assessed a total amount of $595.16
($297.58 X 2 days). 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 or reduce the cost-share assessed for the dates of service April 29, 2021,
and May 06, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for (PET) scan for the initial staging of prostate
cancer for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The
Plan denied your request. The Plan says a PET scan for the initial staging of prostate cancer is not covered.
Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the
correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover a PET scan for
the initial diagnosis and treatment of prostate cancer. Therefore, we decided that the Plan does not have to
provide coverage for (PET) scan for the initial staging of prostate cancer for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement of the nails and the paring or cutting of 
benign hyperkeratotic lesion provided on January 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement of the nails and the paring or cutting of benign 
hyperkeratotic lesion. You say that the provider has no prior knowledge of which patients he will be required to 
see, and once he arrives at the facility, he receives a list of patients who require treatment and provides services 
to all of them. You also say that since most patients require urgent care, it is not possible to request 
authorization before services are rendered. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered.  
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 wound debridement of the nails and the paring or 
cutting of benign hyperkeratotic lesion provided on January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the scanning computerized ophthalmic 
diagnostic imaging provided on December 7, 2021. 
 
You asked the Plan to waive the cost sharing for the ophthalmic diagnostic imaging. You say that you do not 
feel that you should be charged for this visit since it was follow-up for a cataract surgery. The Plan denied your 
request. The Plan says the cataract surgery was more than 90 days prior to the service at issue. As such, the 
copayment was correctly applied. 
 
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 $10 
copayment for Medicare-covered outpatient diagnostic tests.  
 
 You have been asked to pay $10 copayment for the ophthalmic diagnostic imaging. The ophthalmic diagnostic 
imaging falls within the Medicare-covered outpatient diagnostic tests benefit category. There is no provision in 
the contract which indicates that cost sharing would be waived if testing is done as part of follow-up for a 
surgical procedure. 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 cost sharing for the scanning computerized 
ophthalmic diagnostic imaging provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization with stent placement. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
enrollee's condition is not severe. 
 
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. 
 
We looked at the file and the rules. Despite request, the Plan did not provide the records on which they based 
their denial. Furthermore, the Local Coverage Determination, L35998, the Plan used in their decision to deny 
services does not have Medicare Part B jurisdiction where the services will be provided. 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 pre-approve revascularization with stent placement.  
 
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 therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a stairway elevator/lift purchased on 
October 20, 2021. 
 
You asked the Plan to provide reimbursement for a stair lift. You say that this is medically necessary and 
should be considered durable medical equipment in this case. The Plan denied your request. The Plan says this 
is not a Medicare-covered device. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to provide reimbursement for a stairway elevator/lift 
purchased on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
can be received in-network. 
 
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 an office visit provided on July 26, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on October 14, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were just talked to over the 
phone for five minutes. The Plan denied your request. The Plan says the member was in fact seem in person by 
the provider. Therefore, the claim processing, with a $35.00 member copay, stands. 
 
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 an office visit.  
 
You have been asked to pay a $35 copayment for an office visit. an office visit falls within the 
Physician/Practitioner Services, Including Doctors 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 an office visit on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on July 21, 2020 to August 3, 2020 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says There are no submitted medical records to 
determine if testing was appropriate. However, even it appropriate, there were in network labs that could have 
performed this. 
 
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 Drug Testing provided on July 21, 2020 to August 
3, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on June 8, 2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that that is the only location and date 
that you were given, and you were not told that there would be higher charges for going to this location. The 
Plan denied your request. The Plan says you were 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $475 copayment for each Medicare-covered hospital visit.  
 
 
 
 
 
 
 The enrollee has been asked to pay a $475 copayment for each Medicare-covered hospital visit for an 
endoscopy. An endoscopy falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an endoscopy provided 
on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diabetic shoes and inserts provided on July 
21, 2021. 
 
You asked the Plan to waive the copayment for diabetic shoes and inserts. You say that you had no idea you 
had coinsurance for your diabetic shoes. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for diabetic shoes and therapeutic inserts. 
 
You have been asked to pay $65.82 (allowed amount=$329.18 x 20%=$65.82) for diabetic shoes and inserts. 
Diabetic shoes and inserts fall within the Diabetic Services and Supplies 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 diabetic shoes and inserts provided on July 21, 2021.