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

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to 
compression and other maneuvers provided on November 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a duplex scan of extremity veins including responses to compression and other 
maneuvers. You say that your desired outcome to have the bill paid. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan, and they have also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 
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 a duplex scan of extremity veins including 
responses to compression and other maneuvers provided on November 12, 2021, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on January 7, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that your mom has not had an exam in 
two years. You say that this should be covered. The Plan denied your request. The Plan says the benefit limit 
for D0150 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. The Plan covers a 
comprehensive oral evaluation once every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on February 14, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by an out-of-network provider on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (NCS) (95911), and Needle 
electromyography (95886) provided on December 15, 2021. 
 You asked the Plan to pay for codes 95911 and 95886. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95911 is Nerve conduction studies; 9-10 studies. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 95911. Our reviewer says that the medical records do 
not support the billing of code 95911. Our reviewer found the records provided for review make mention of an 
EMG having been performed. However, the records did not contain the results of an NCS study. There was no 
documentation provided showing the recorded values for the nerves tested (e.g. CV, amplitude, etc). In the 
absence of adequate documentation of the procedure the records cannot be said to support the billing of code 
95911 provided on December 15, 2021. 
 
We have also confirmed that code 95886 is an add-on code. As the primary code, 95911 is not payable, the 
add-on code, 95886, is also not payable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95911 and 95886 have not been met. Therefore, we decided that the Plan 
does not have to pay for the nerve conduction studies (NCS) (95911), and Needle electromyography (95886) 
provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that the service was a medical necessity. The Plan 
denied your request. The Plan says the service is 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 cone beam CT is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation (D0364) provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam (code D0150) you received 
on January 1, 2022. 
 
You asked the Plan to pay for the comprehensive dental exam. You say that you believe that because you had 
to begin care with a new dentist, a new comprehensive exam should be covered. The Plan denied your request. 
The Plan says you were not eligible for coverage of a comprehensive dental exam on this date of 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. Specifically, your dental plan 
only covers comprehensive dental exams (code D0150) once every three years.  Records show that you 
received a covered comprehensive dental exam on April 6, 2021.  
 
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 
comprehensive dental exam (code D0150) you received on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have a copayment 
since you met your out-of-pocket maximum. 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 $30 
copayment for specialist services.  
 
The file shows that claims from earlier in the year were reprocessed by the Plan and removed from your 
maximum out-of-pocket (MOOP) total, which put the total amount under the cap.  Therefore, you have been asked to pay a $30 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 a specialist office visit provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits and a routine venipuncture provided on 
September 27, 2021, to November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visits and a routine venipuncture. You say that your desired outcome is to 
have the bills paid. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan, and the services were not referred by a network provider or rendered in an in-network facility. The Plan 
also says that they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. 
 
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 office visits and a routine venipuncture provided 
on September 27, 2021, to November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on May 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed a root canal and do not understand 
why you cannot be reimbursed if the dentist doesn't accept Medicare. The Plan denied your request. The Plan 
says services with a provider who has opted out of Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services you received on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract eye surgery. 
 
You asked the Plan to pre-approve cataract eye surgery. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Based on this information, we decided that 
Medicare rules for coverage of cataract eye surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cataract eye surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hygiene instructions (D1330), and gingival irrigation 
(D4921) by a participating provider on January 24, 2022. 
 
You asked the Plan to pay for hygiene instructions and gingival irrigation. You say that you were not aware of 
what is covered and what is not covered. The Plan denied your request. The Plan says the rendered dental 
services have been correctly denied. 
 
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 hygiene 
instructions (D1330), and gingival irrigation (D4921) by a contracted provider on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 83631, 89055, 83520, 83631, 89055) 
provided August 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (83520, 83631, 89055, 83520, 83631, 89055) provided August 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation provided during a procedure provided 
on July 13, 2021, billed with code 99152. 
 
You asked the Plan to pay for the moderate sedation services. You say that the records support payment for this 
claim. The Plan denied your request. The Plan says the code 99152 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
the presence of an independent trained observer as required by the code definition. Based on this information, 
we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, 
we decided that the Plan does not have to pay for the moderate sedation provided during a procedure provided 
on July 13, 2021, billed with code 99152.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided November 2, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81455 is non-covered by Medicare. 
 
We looked at the file and Medicare rules. The code at issue is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81455) provided November 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you reached your out-of-
pocket limit and you do not believe you should be charged for this service. The Plan denied your request. The 
Plan says you were charged this cost sharing correctly.  Please note your in-network maximum out-of-pocket was not met at the time this claim was submitted. 
 
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 $250 
copayment for each ambulance trip. You had one (1) ambulance trip. The Plan charged you $250 for these 
services. 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 ambulance services provided on  
December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT of the abdomen and pelvis provided on August 3, 2021. 
 
You asked the Plan to pay for a CT of the abdomen and pelvis. The Plan denied your request. The Plan says the 
CT abdomen and pelvis performed on August 3, 2021 was not authorized care as it had been denied on a pre-
service organization determination. Therefore, the professional interpretation of the scan performed is also not 
authorized care. 
 
The Plan contract says that the Plan will cover services from either network or out-of-network providers, as 
long as the services are covered benefits and are medically necessary. 
 
We looked at the file and the Plans rules. The Plan did not pre-approve the service at issue. The file shows that 
the Plan denied coverage for the requested CT scan on a preservice organization determination. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for a CT of the abdomen and pelvis provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography services provided to the enrollee on
July 13, 2021, and billed under code 74176.
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 claim was previously paid. Maximus overturned the Plans denial as the case file
lacked documentation to show the claim had been paid. The Plan requested a reopen and provided a copy of the
paid claim.
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, the Plan has provided documentation to show these services were
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 computed tomography services provided to the enrollee on July 13, 2021 and
billed under code 74176.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiopharmaceutical localization of a tumor (78803) and 
the Iodine 1-123 ioflupane, diagnostic, per study dose (A9584) rendered by the out-of-network (OON) provider 
on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 Point of Service benefit allows enrollees to access other 
services from non-network providers with a referral from their primary care physician. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
A referral was not provided by the enrollees primary care physician. We found no exception that would 
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the 
radiopharmaceutical localization of a tumor (78803) and the Iodine 1-123 ioflupane, diagnostic, per study dose 
(A9584) rendered by the out-of-network (OON) provider on December 29, 2021.