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

We decided that the Plan does not have to waive the $121.01 cost share charged for outpatient hospital services
provided on April 20, 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 billed by your provider
and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct contract 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. Your contract with the Plan clearly says that you must pay $395 copayment for
outpatient hospital services.
In this case, you are being charged less than the normal copayment expectation for the services provided. 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 $121.01 cost share charged for outpatient hospital services provided on
April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve the bioimpedance spectroscopy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 the bioimpedance spectroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient published evidence to assess the role of bioimpedance in the 
clinical assessment of patients with lymphedema, the safety and/or impact on health outcomes or patient 
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 the bioimpedance spectroscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the bioimpedance spectroscopy (BIS) (93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An office visit provided on October 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office 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 office visit provided on October 25, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from October 18, 2021, 
to October 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you requested an authorization up to the 
date the enrollee was discharged on October 22, 2021, but it was denied. The Plan denied your request. The 
Plan says an authorization was approved for September 18, 2021, to October 17, 2021. There was no approved 
authorization for the out-of-network provider from October 18, 2021, to October 22, 2021. Therefore, the 
services rendered during those dates were denied. 
 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 inpatient hospital care provided from October 
18, 2021, to October 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you have type 1 diabetes. The Plan 
denied your request. The Plan says the documentation is lacking a treatment regimen with insulin to support 
medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (code D4355) you received on 
September 21, 2021. 
 
You asked the Plan to pay for the full mouth debridement. You say that your dentist said this procedure was 
medically necessary and you believe that this should be covered at least 50%. The Plan denied your request. 
The Plan says this service is not covered under your dental plan. 
 
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. Your contract explicitly states 
that only those dental services listed on pages 109 and 110 of your Evidence of Coverage are covered.  Full 
mouth debridement (code D4355) is not listed as a covered service. 
 
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 full 
mouth debridement (code D4355) you received on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic or therapeutic injection(s) provided on January 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic or therapeutic injection(s). You say that you confirmed benefits and 
eligibility before providing service to the patient. The Plan denied your request. The Plan says the provider is 
out-of-network, and prior authorization is required. The Plan also says that there are doctors in-network near 
the enrollees home that could take care of this problem. 
 
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 diagnostic or therapeutic injection(s) provided on 
January 13, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 10, 
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 the denied codes remain not supported. 
 
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 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 laboratory services provided to the enrollee on June 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 neuropsychological testing evaluation services (96133 
x5). 
 
You asked the Plan to pre-approve the neuropsychological testing evaluation services. The Plan denied your 
request. The Plan says these services are not medically necessary 
 
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 the neuropsychological testing 
evaluation services. Our reviewer says that the neuropsychological testing evaluation services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provider has 
requested appeal for the additional hours denied. our reviewer found that test evaluation services (1 unit or 1 
hour of 96132 and 7 units or 7 hours of 96133, a total of 8 hours) were approved. Five (5) hours or 5 units of 
test evaluation services (96133) were not approved. If the testing time exceeds 8 hours, medical necessity for 
the extended time should be documented. Our physician reviewer also found that the the items/services at issue 
in this case are not medically reasonable and necessary. 
 
 
  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 neuropsychological testing evaluation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 5 neuropsychological testing evaluation 
services (96133 x5).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a breast ultrasound provided on December 
27, 2021. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you should have a $50 copayment 
for testing at an independent diagnostic testing center. You also say that last time you had this test done the 
copayment was $50. 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 $200 
copayment for diagnostic testing, including ultrasounds at all locations of service.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $113.59, which is less than the $200 copayment for an ultrasound. An ultrasound falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for a breast ultrasound provided on December 27, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to hold you harmless beyond the applicable cost-sharing for outpatient surgery 
provided on November 19, 2021. 
 
You asked the Plan to hold you harmless beyond the applicable cost-sharing for outpatient surgery. You say 
that your copayment is only $200 so you should be refunded the extra amount you paid. The Plan denied your 
request. The Plan says that the denial of payment for this service is correct, because the Plan was unable to 
verify with the provider that you would be refunded for the excess amount paid. 
 
The Plan must follow Medicare rules. Medicare rules say that for a Plan-contracted provider, the enrollee does 
not pay balance billing.  
 
We looked at the file and Medicare rules. This provider is in-network with the Plan; therefore, you cannot be 
held responsible for the balance bill of this claim. The Plan is also not responsible for paying the balance bill of 
this claim; however, since the provider is contracted with the Plan, the Plan must ensure that you are held 
harmless for the balance bill. The Plan says that they were unable to confirm that you would be refunded for 
the balance bill of this claim at the time of their reconsideration decision. Therefore, we decided that the Plan 
has to hold you harmless beyond the applicable cost-sharing for outpatient surgery provided on November 19, 
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 pay for the dental services (D0140 and D0220) provided on October 
15, 2021. 
 
You asked the Plan to pay for dental codes D0140 and D0220. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says dental codes D0140 and D0220 are not 
covered under the Plan's 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, dental codes D0140 and D0220 are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the dental services (D0140 and D0220) provided on October 15, 2021. The Plan agreed to pay for dental code D3320, leaving you with your 50% coinsurance for dental code D3320.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve the requested brand of glucose testing strips for the enrollee.
You asked the Plan to pre-approve a specific brand of glucose testing strips. You say that the requested test
strips are medically necessary. The Plan denied your request. The Plan says the requested test strips are not
covered under the Plan benefit. Maximus overturned the Plans denial. The Plan requested a reopen and stated
in the Evidence of coverage, it is clearly documented that the requested test strip is not a covered brand. Also,
the insulin pump mused by the enrollee has a continuous glucose monitor (CGM) but the information provided
by CGM systems is intended to supplement, not replace, blood glucose information obtained using a home
glucose meter; therefore, not supporting an absolute requirement of use of this component of the system.
The Plan is correct in this case, Medicare rules say that plans can require enrollees to use specific providers and
specific brands. The Evidence of Coverage clearly outlines that covered brands available. The brand requested
is not covered. Therefore, we decided that the Plan does not have to pre-approve the requested brand of glucose
testing strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
January 8, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you do not understand how 
the frequency limitation for this service has been exceeded, because this is the first time that you have 
undergone an ultrasound scan, as ordered by your doctor for your condition. You also say that this x-ray was 
ordered by your general practitioner as medically necessary. The Plan denied your request. The Plan says your 
benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 8, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the additional intraoral periapical x-ray (D0230) provided on January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spectrometry testing (83789) provided on May 21, 2021. 
 
You asked the Plan to pay for spectrometry testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed. 
We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this 
testing was performed as validity testing for the specimen used for drug testing. Based on this information, we 
decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that 
the Plan does not have to pay for spectrometry testing (83789) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telephone evaluation and management (E/M) services
represented by code 99442 provided on May 20, 2021.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial for insufficient claim information. The Plan requested a reopen and provided additional information. The
Plan says 99442, was rendered by the provider on May 20, 2021, and is defined by CMS as a telephone
evaluation and management service provided by a physician to an established patient, parent, or guardian not
originating from a related E/M service provided within the previous seven days nor leading to an E/M service
or procedure within the next 24 hours or soonest available appointment: 11-20 minutes of medical discussion.
Further review of the claim history shows that there is an E/M service 99204 provided on May 13, 2021, which
is billed and paid by the plan. This is billed prior to the seven days from the appealed date of service May 20,
2021. Additionally, in both the first E/M visit and the second Telehealth E/M visit the Dx code used in the
primary position was M96.1. The primary pointer is used to identify the reason for the E/M visit and as such
this indicates the provider has self-reported that both visits were for the same Dx. Therefore, the Medicare
billing criteria are not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate code. In this case, this claim
cannot be paid as billed due to an inappropriate use of the diagnosis code. Medicare rules for coverage of this
claim have not been met. Therefore, we decided that the Plan does not have to pay for telephone evaluation and
management (E/M) services represented by code 99442 provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint 
nerves provided on January 8, 2021. 
 
You asked the Plan to pay for the SI joint RFA procedure. You say that this was a medically necessary 
treatment. The Plan denied your request. The Plan says this treatment is considered investigational. 
 
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 pay for the SI joint RFA procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary. 
 
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 SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves provided on 
January 8, 2021.