Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral x-
rays (D0210) provided by an out-of-network provider on May 19, 2021, to May 21, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral x-rays. You say that you would 
like the Plan to reimbursement you for these services. The Plan denied your request. The Plan says this claim 
has been correctly processed and paid. 
 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 Plan covers a 
comprehensive oral evaluation and intraoral x-rays when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and intraoral x-rays have not been met. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral x-rays (D0210) 
provided by an out-of-network provider on May 19, 2021, to May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials provided on May 19, 
2021. 
 
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully 
support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the 
code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not 
eligible for separate reimbursement. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not 
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials 
provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20930, 20936) provided on March 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Codes 20930 and 20936 are assigned a status indicator of B under 
the Physician Fee Schedule, which means that these are bundled service. Payment for these services is bundled 
into payment for other services. No separate payment can be made for these services. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20930, 20936) provided on March 9, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the ophthalmological medical examination and 
evaluation (92014) provided on June 4, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not include medical records for our organization to 
review and determine if the service provided in this case was for the examination and treatment of cataracts as 
indicated. Therefore, we decided that the Plan has to waive the copayment for the ophthalmological medical 
examination and evaluation (92014) provided on June 4, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for arthrocentesis (20611-RT) provided on April 8, 2021. 
 
You asked the Plan to pay for arthrocentesis. You say that this was a separate procedure performed. The Plan 
denied your request. The Plan says that the denial of payment for this service is correct. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any rationale for this denial of payment nor any 
evidence to support a denial of payment. You appealed with supporting records showing that the billed 
procedure 20611-RT was performed. With no rationale or evidence to support a denial, the Plan has not shown 
that their decision to deny payment for this service is correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pay for arthrocentesis (20611-RT) provided on April 8, 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 pre-approve a Catalys surgery with Toric intraocular lens (IOL).
You asked the Plan to pre-approve a Catalys surgery with Toric IOL. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers specific vision services. We looked at the file and the Plan's rules. A standard intraocular lens could be evaluated if requested, but not a specialized lens. Based on this information, we decided that the Plan's rules for coverage of a Catalys surgery with Toric IOL have not been met. Therefore, we decided that the Plan does not have to pre-approve a Catalys surgery with Toric intraocular lens (IOL).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (78832) provided on January 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 78832
is a column II code to column I code 79445. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (78832) provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313).

You asked the Plan to pre-approve an expandable controller (E2377, E2313) and a power seat elevation system
(E2300). You say that this equipment is medically necessary for the enrollee. The Plan denied your request.
The Plan says Medicare coverage criteria are not met. Maximus partially overturned the Plans denial and
approved the expandable controller (E2377, E2313) and denied the power seat elevation system (E2300). The
Plan requested a reopen regarding the expandable controller and stated that Maximus did not apply the correct
criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller. The Maximus Physician Reviewer determined that there is documentation that the requested
expandable controller is medically necessary to operate 3 or more powered seating actuators through the drive
control. The enrollee has 2out of 5 upper extremity strength and is dependent for all activities of daily living
including feeding, grooming and hygiene. The Plan argues that only two power features (tilt and elevating leg
rests) were approved. The Plan states that, in the presence of only two power features, an expandable controller
cannot be approved. The Plan is correct in this case. There are two approved power options on the enrollee's
power wheelchair - tilt and elevating leg rests. It is not medically necessary to control the power options
through the joystick; the power options can be controlled by their own switches. The enrollee will not be
operating 3 or more powered seating actuators through the drive control.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller are not met. Therefore, we decided that the Plan does
not have to pre-approve an expandable controller(E2377, E2313).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 29,
2020.
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. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is whether the use of CPT code
14001 is supported by the medical records. The Maximus Reviewer determined that the operative report
documents additional incisions along with extensive undermining. Per CPT guidelines for adjacent tissue
transfer, "Undermining alone of adjacent tissue to achieve closure, without additional incision does not
constitute adjacent tissue transfer, see complex repair codes 13100 -13160." If an additional incision is not
performed, you would report a complex repair code. Therefore, CPT 14001 is confirmed as performed.
The Plan argues that documentation of a flap requires that the following four separate items be clearly
documented: "Orientation of the incisions with respect to the defect, Documentation of extensive undermining,
Documentation of the primary defect, and Documentation of the secondary defect".
The medical records show the enrollee underwent excision of a 2.1 cm cyst of the right mid back, with
reconstruction of a 6.0 x 2.0 cm defect with medial and lateral right mid back advancement flaps with plastic
surgical closure. The Operative Report states, "In order to reconstruct this 6.0cm x 2.0cm defect, additional
separate incisions were made to develop full thickness skin and subcutaneous skin advancement flaps. The skin
was also undermined for several centimeters above the fascia and muscle creating the opposing medial and
lateral right mid back skin flaps. These skin flaps were then advanced one to the other and then the paraspinal
fascia layer and deeper subcutaneous layers were secured with multiple inverted 2-0 vicryl sutures. Then the
subcutaneous and dermal tissue was approximated with multiple inverted 3-0 vicryl sutures. The skin edges
were then precisely co-apted with multiple interrupted and continuous running 3-0 Nylon sutures."
Our Medical Director has concluded that the Plan is correct in this case. The documentation is insufficient to
support the use of CPT / HCPCS Code 14001: adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq
cm to 30.0 sq cm.
We looked at this coder'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 pay for surgical services provided to the enrollee on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the aflibercept injection and ophthalmic imaging 
provided on June 11, 2021. 
 
You asked the Plan to waive the cost for the aflibercept injection and ophthalmic imaging. You say that you are 
being billed over $400 and want to know why Medicare isn't picking this up. You say that you cannot afford 
this and don't want to go blind. The Plan denied your request. The Plan says the cost share 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% of 
the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs and a $40 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual 
glaucoma screening for members at high risk.  
 
You have been asked to pay a total of $408.70 for the aflibercept injection and ophthalmic imaging.  
 
Service Allowed Amount Standard Cost Member Liability 
Aflibercept Injection $1,843.51 20% $368.70 
Ophthalmic Imaging $43.35 $40 $40 
TOTAL:   $408.70 
 
The aflibercept injection falls within the "Medicare Part B prescription drugs" benefit category. The ophthalmic 
imaging falls within the "Vision 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 cost for the 
aflibercept injection and ophthalmic imaging provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure code 99072) provided to the enrollee on January 7, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease." 

We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (procedure code 99072) provided to the enrollee on January 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on June 30, 2021, and July 2, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that it was out of your 
control as the nurse called the ambulance the first time and then you were told by the nurse to call the 
ambulance if it happened again. The Plan denied your request. The Plan says non-transport by an ambulance is 
not covered by Medicare or your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 30, 2021, and July 2, 2021. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and 
treatment, no transport (A0998) provided on June 30, 2021, and July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on June 4, 2021.

You asked the Plan to pay for the hearing aids. You say that you previously bought these hearing aids and found that they allow you to hear better than ones prescribed from the audiologist. You say that the Plan covers hearing aids, and you should be reimbursed. The Plan denied your request. The Plan says internet purchases are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's hearing vendor. 

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were purchased online. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) provided on November 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the telemedicine visit. You say that please see the attached and reprocess with authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 the telephone evaluation and management service (99442) provided on November 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 24,
2020 and billed under code 11046.

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 the records provided do not support the services billed. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, billed code 11043 (and, therefore 11046) is a column 1/column 2
restriction. There was no modifier billed on cod 11043. Therefore, code 11046 would only potentially be
covered if code 11043 was billed correctly, which it isn't with the NCCI edit. Code 11046 is only payable as
an add-on code to 11043. Therefore, we decided that the Plan does not have to pay for surgical services
provided to the enrollee on December 24, 2020 and billed under code 11046.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 6, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you had an emergency room visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 Emergency care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on May 6, 2021. You have been asked to pay a $65.11 copayment for the emergency room visit, which is less than the contracted $90 copayment amount. The 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 the emergency room visit provided on May 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on May 6, 021. 
  You asked the Plan to pay for the occupational therapy services. You say that you have included the medical 
records required to reprocess the denied claim. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as 
services incident to a physician/non-physician practitioner?s service must meet all incident requirements.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided 
by an occupational therapist on May 6, 021.