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

 
We decided that the Plan does not have to pay for the surgical placement of an implant body, endosteal implant 
(D6010) provided on December 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual dental policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical 
placement of an implant body, endosteal implant (D6010) provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel services rendered on January 25, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that six or more pathogens were tested. 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 the respiratory panel services rendered on January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to waive the copayment charged for an X-ray provided on August 18, 2021.
You asked the Plan to waive this copayment. You say that you believed all services provided due to COVID-19
related illness would be covered. The Plan denied your request. The Plan says this copayment was charged
based on the services provided and the claim submitted by your provider. Maximus overturned the Plans denial
for insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan noted that while any treatments related to COVID-19 are covered, your normal member cost share for
each service will apply.
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 this is a cost share for imaging services. 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. Medicare is not requiring or approving the waiver of copayments
or coinsurance for services rendered just because they are related to COVID-19. While the services provided
are "covered" in the sense that some services not normally provided with any type of frequency, such as x-rays,
are being covered due to the treatment and/or recovery from COVID-19, any related contractual cost share still
applies. Therefore, we decided that the Plan does not have to waive the copayment charged for an X-ray
provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $45 cost share charged for a breathing capacity
test (94010) provided on March 12, 2021.
You asked the Plan to waive 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 charged 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 applied the incorrect contract language.
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 $45 copayment for outpatient routine radiology. The Plan has demonstrated that
you are enrolled in the contract that requires a $45 copayment for these services.
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 $45 cost share charged for a breathing capacity test
(94010) provided on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided the Plan does not have to pay for skilled nursing services provided from May 1, 2021, to May 3,2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you were given notice that further services would not be covered after
April 29, 2021. Maximus overturned the Plans denial for lack of documentation of the notice provided in the
case file. The Plan requested a reopen and provided that documentation.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for care
in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. The
Plan provided a copy of the notice you signed on April 27, 2021, stating coverage would end as you no longer
met the criteria needed for this type of care. The medical records show as of April 27, 2021, you no longer
required daily skilled nursing or daily skilled therapy services in this type of facility. You chose to continue to
receive services with notice of non-coverage. Therefore, we decided that the Plan does not have to pay for
skilled nursing services provided from May 1, 2021, to May 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 2, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. Medicare rules say that a contract 
provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by 
the plan unless notice is provided that the services will not be covered. The plan follows these rules. 
 
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 specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on September 2, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for a rhythm electrocardiogram provided to the enrollee on January
30, 2021 and billed under code 93042.
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 are not met. Maximus overturned the Plans denial for
insufficient information in the file regarding the edit claimed to exist between codes 93042 and 99291. The
Plan requested a reopen and notes a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP)
edit exists between 99291and 93042. This PTP edit has a modifier indicator of 0, which indicates modifiers
associated with NCCI are not allowed. The Plan provided a copy of the American Medical Association billing
guidelines showing code 99291 is listed as a column one code and code 93042 is listed as a column two code,
with a modifier indicator of zero.
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
cannot be paid as billed due to code 93042 being a column two associated code with 99291.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for a rhythm electrocardiogram provided to the enrollee on January 30, 2021 and billed under code
93042.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy services provided on April 2, 2021, and 
April 6, 2021, billed with code 97140. 
 
You asked the Plan to pay for the manual therapy services. You say that the services were medically necessary 
and should be paid in full. The Plan denied your request. The Plan says all services were approved for payment 
except for 97140, as the time spent providing this service is not documented. 
 
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 97140 is Manual therapy techniques (eg, mobilization/ 
manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. 
 We find that CPT code 97140 is not supported in the medical record. Specifically, this is a timed code, and the 
time spent providing this service is not documented in the record. Based on this information, we decided that 
Medicare rules for coverage of the manual therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the manual therapy services provided on April 2, 2021, and April 6, 2021, billed 
with code 97140.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction with an oral surgeon. You say that you are in pain and 
need your tooth extracted. The Plan denied your request. The Plan says this service is not covered when 
provided by an oral surgeon. 
 
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 tooth 
extraction when performed by a participating general dentist.  
 
We looked at the file and Medicare rules. The service in this case is requested to be performed by an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction with an 
oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) to be provided by an oral 
surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2022. 
 You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that a panel of genetic testing was completed. The documentation does not support 
that all genes in this panel are relevant to the enrollees personal and family history. This means that the genetic 
testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 81241, 
81240, 81220, 81227, 81230, 81291, and 81355 provided September 1, 2021. 
 You asked the Plan to pay for the laboratory services. You say that please find the attached documents for 
further review of the claim. Kindly reconsider the payment to the claim. The Plan denied your request. The 
Plan says does not meet Medicare NCD/LCD criteria. 
 
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, if one laboratory procedure evaluates multiple genes using a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 
(Unlisted molecular pathology procedure) with one unit of service. Procedures reported together must be both 
medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is 
treating the beneficiary and using the results in the management of the beneficiary's specific medical problem. 
If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure.  Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic 
testing coded as 81241, 81240, 81220, 81227, 81230, 81291, and 81355 provided September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) of the skull for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no history of malignancy. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable or necessary. Our physician reviewer found prior PET/CT (computed 
tomography) has been used to assess the metabolic nature of sarcoid in this patient as the condition is FDG-18 
avid. Medicare guidelines allow for PET/CT to be used in occasional circumstances when the physiologic 
assessment of a condition is best analyzed even when there is no known malignancy. This case is such an 
instance where the condition is difficult to treat and monitor and has proven to be PET avid in the past. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
positron emission tomography (PET) of the skull for the enrollee.  
 
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 teal frame color (K0108). 
 
You asked the Plan to pre-approve the frame color. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the teal frame color does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the frame color have not been met. Therefore, we decided that the Plan does not have to pre-
approve teal frame color (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce any of this cost share.
You asked the Plan to waive this cost share. You say that you do not believe this cost share in correct. The Plan
denied your request. The Plan says this cost share was charged based on the services rendered and the Plan
contract. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated the Plan
submitted for 2021 contract for review in error and Maximus used the 2021 contract for its review, also in
error. The Plans states that for the Inpatient Hospital stay May 01, through May 09, 2020, the provider billed
the plan in the amount of $85,524.00 and the contracted amount is $6,363.00. As per evidence of coverage
"$250 copayment each day for days 1 to 8 for Medicare-covered hospital care." $250 x 8= $ 2,000.00. The total
copayment of $2,000.00 was applied correctly. The Plan paid the remaining balance of $4,363.00. For the
Inpatient Hospital stay May 22, through June 04, 2020, the provider billed the plan in the amount
of $106,763.00 and the contracted amount is $20,818.79. As per evidence of coverage "$250 copayment
each day for days 1 to 8 for Medicare-covered hospital care.
The Plan states you met your out-of-pocket maximum on this claim. The out-of-pocket maximum is $3,400.00.
You had used $2,000.00 before this date of service. You had $1,400.00 remaining on their out-of-pocket
maximum limit. The copayment for this claim would have been $2000.00, as the remaining out-of-pocket
maximum was $1,400.00. The member was assessed a copayment of $1,400.00. The total copayment of
$1,400.00 was applied correctly. The plan paid the remaining balance of $19,418.79.
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 $250 per day for days 1 to 8 of each inpatient stay. 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
$3400 cost share charged for inpatient care provided from May 1, 2020, to June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on November 16, 2021. 
 You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The cytopathology services at issue in this appeal were requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the cytopathology services provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the injections 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the LCD 
coverage criteria are met. 
 
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 injections. Our reviewer says that 
the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer found 
that the medical records do not show that the enrollee has recently tried conservative therapies for her pain for at least six weeks including medications, activity modifications, physical therapy, or home exercise. In 
addition, the enrollee has neuropathy in both lower extremities. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), and 
prophylaxis (D1110) provided on February 16, 2022, by an out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you received a bill for this 
appointment. You say that your insurance only paid $53.90. You say that this leaves you with a larger out of 
pocket cost that you did not expect. You also say that your insurance should pay the same as they did last year. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
there is a 30% coinsurance when they are received out of network. This is a contractual obligation you agreed 
to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan does not have to pay an 
additional amount for the oral exam (D0120), and prophylaxis (D1110) provided on February 16, 2022, by an 
out of network dentist.