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

 
We decided that the Plan does not have to pay for an Acupuncture provided on November 30, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an Acupuncture. You say that that you were misinformed about requiring prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Acupuncture provided on November 30, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the gene panel provided was billed with multiple codes. If a single procedure is performed, 
only one 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 lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) and panoramic radiographic image (D0330) provided March 1, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographs and panoramic x-rays. You say that this is the 
only time you have had a panoramic x-ray. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for the panoramic x-ray and the 2D photographs are not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete 
series or panoramic x-rays once every 5 calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
radiographic images was covered on the same date of service. Based on this information, we determined that you have exceeded the frequency limit for coverage the panoramic x-ray. Though the Plan offers dental 
benefits in excess of Medicare coverage, the 2D oral/facial photographic image are not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) and panoramic radiographic image (D0330) provided March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs or medicaments dispensed in the office for 
home use (D9630) and clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve the requested dental services. You say that these services are medically 
necessary for your condition. The Plan denied your request. The Plan says these requested services are not 
among those covered under your supplemental dental benefit. 
 
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. 
 
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 the 
drugs or medicaments dispensed in the office for home use (D9630) and clinical crown lengthening (D4249).
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to provide coverage for right side varicose vein ablation treatment.
You asked the Plan to provide coverage for right and left vein treatment. You say that this treatment is
medically necessary. The Plan denied your request. The Plan says while the left side was approved, the
requested right endovenous ablation and bilateral stab phlebectomy remains denied due to lack of medical
necessity for the service. Maximus partially overturned the Plans decision approving the left side and not the
right side. The Plan requested a reopen and stated that Maximus basically made the same decision.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare specific coverage criteria for
this type of treatment. We asked our physician reviewer to carefully review the case file and apply the relevant
Medicare. Our physician reviewer determined the left side meets criteria; however, the right side does not meet
criteria because there is a subacute thrombus. The Right side does not meet the required criteria.
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 requested treatment are not met. Therefore, we decided that the Plan does
not have to provide coverage for right side vein treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), prophylaxis 
(D1110), resin-based composite of two surfaces (D2331), resin-based composite of three surfaces (D2332), 
maxillary partial denture (D5213), and mandibular partial denture (D5214) provided from July 26, 2021, to 
August 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, prophylaxis, resin-based composites, and 
dentures. You say that you went to an OON provider as a result of your general dentist was having problems 
making your dentures The Plan denied your request. The Plan says services provided by an OON, or non-
contracted provider are not provided under this benefit program. The Plan also says that you self-referred to an 
OON dental provider, and you did not contact the Plan prior to seeking care with an OON provider.  
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431), prophylaxis (D1110), resin-based composite of two surfaces (D2331), 
resin-based composite of three surfaces (D2332), maxillary partial denture (D5213), and mandibular partial 
denture (D5214) provided from July 26, 2021, to August 13, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - mandibular (CPT code D5120) and 
complete denture - maxillary (CPT code D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you were fitted for dentures and received 
dentures that never fit properly. The Plan denied your request. The Plan says you exhausted your benefit 
frequency limit. 
 
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. 
 
Review of the records show that you received  complete denture - maxillary (CPT code D5110) and mandibular 
partial denture (CPT code D5214) on February 7, 2022. Therefore, you exhausted your benefit limit. Your 
2022 EOC states that complete dentures (upper and lower) (one (1) upper complete and 1 lower complete 
denture every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (1 
upper and/or 1 lower partial denture every 5 years, including routine post-delivery care). Includes necessary 
extractions to fit dentures (unlimited). Therefore, we decided that the Plan does not have to pre-approve 
complete denture - mandibular (CPT code D5120) and complete denture - maxillary (CPT code D5110).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, breast, without and with contrast material(s), including 
computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), 
when performed; bilateral (CPT code 77049) and PET with concurrently acquired CT for attenuation correction 
and anatomical localization imaging; skull base to mid-thigh (CPT code 78815). 
 You asked the Plan to pre-approve the services. You say that you never had the original MRI done and you 
really need this scan done soon in order to proceed with surgery. The Plan denied your request. The Plan says 
that a study similar to the one requested (CPT code 77049) has already been approved for you The Plan states 
for CPT code 78815 the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found Medicare coverage allows the PET CT to look for distant metastasis; thus, the PET CT is approved per 
NCD. Furthermore, the MRI determines disease extent more accurately than mammography and physical 
examination in many patients; therefore, the MRI is approved. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve MRI, breast, without and with contrast material(s), including computer-aided detection (CAD real-
time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (CPT code 
77049) and PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815).  
 
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 that the Plan does not have to waive the coinsurance for an ultrasound of the aorta provided on 
January 26, 2022. 
 
You asked the Plan to waive the coinsurance for an ultrasound. You say that you have had this service in 
previous years and did not get billed for it. You also say the hospital is harassing you with phone calls and text 
messages to pay the bill. 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 20% 
coinsurance up to $75 per day for diagnostic radiology services, including ultrasounds.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$23.69, which is 20% coinsurance of the allowed amount for an ultrasound ($118.45 allowed amount x 20% 
coinsurance = $23.69). An ultrasound falls within the diagnostic radiology services, including ultrasounds 
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 coinsurance for an ultrasound of the aorta 
provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on January 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not 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 the duplex scan provided on January 3, 2022 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 a telehealth specialist visit provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for a telehealth specialist visit. You say that you are being charged 
two copayments and the doctor called you directly. 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 a telehealth specialist visit.  
 You have been asked to pay a $30 copayment for a telehealth specialist visit. A telehealth specialist 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 a telehealth specialist visit provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 11, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are the only provider that provides the 
specific test, and the treating physician sent the test to your laboratory. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no approved 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 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 laboratory services provided on March 11, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided January 7, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you had planned to sign up for extra dental 
coverage. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) provided January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Psychotherapy Services provided on January 4, 2022 by an out-of-network (OON) provider.

You asked the Plan to pay for Psychotherapy Services. You say that you would like to appeal the denial of the claim. 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 Psychotherapy Services provided on January 4, 2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on February 9, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
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 75743 is angiography, pulmonary, bilateral, selective, 
radiological supervision and interpretation.  
 
We find that CPT code 75743 is not supported. Specifically, radiological services are included in the approved 
transcatheter therapy provided on the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the angiography services provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided December 6, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this appointment was a dental 
emergency. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on January 21, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) and the paring or cutting of 
benign hyperkeratotic lesions (11056) rendered by the out-of-network (OON) provider on January 26, 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 nail debridement (11721) and the paring or cutting of benign hyperkeratotic 
lesions (11056) rendered by the out-of-network (OON) provider on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on November 30, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the acupuncture services. You say that you spoke to the Plan and were told an 
authorization was not needed to provide service to the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the Plan reviewed 
its records and determined the call references was for another enrollee and there was no call history on file 
regarding an authorization for the service provided to the enrollee. 
 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 acupuncture services provided on November 
30, 2021, by an OON provider.