Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on July 01, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for x-rays provided on July 
01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you feel you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 8, 2022. 
 
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 the services are not covered. 
 
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 enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on September 8, 2022.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the neck. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that there is no physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the 
CT scan of the neck is medically necessary. Our physician reviewer found that the enrollee has chronic rhinitis, 
and the plan has approved CT of the neck with contrast. The enrollee has had allergic reaction to contrast in the 
past and has attempted to contact physician in order to change the order to CT neck without contrast but has 
been unsuccessful. With the CT of the neck already approved with contrast the previous reaction to contrast 
means the repeat of same injection would be contraindicated therefore the request by the enrollee to have an 
order approved for CT of the neck without contrast is reasonable and the exam should be approved since the 
clinical indication for the CT study remains present and unchanged. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the neck.  
 
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 compression stockings identified with code E1399. 
 You asked the Plan to pre-approve the compression stockings. You say that you have a blood clot in your leg. 
The Plan denied your request. The Plan says the medical criteria for compressions stockings have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
E1399.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 You asked the Plan to pre-approve the compression stockings. You say that you do not understand why this is 
not covered. The Plan denied your request. The Plan says the requested compression stockings have been 
correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 17, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you needed the dental service done so you could 
get extractions and did not know there were limits. The Plan denied your request. The Plan says your benefit 
for the requested item or service 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of August 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of hyperplastic alveolar mucosa (41828) 
provided on July 11, 2022. 
 
You asked the Plan to pay for the dental service. You say that the enrollee was referred to you by their general 
dentist and the procedure was necessary. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the excision of hyperplastic alveolar mucosa is not covered by the Plan. 
 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
excision of hyperplastic alveolar mucosa (41828) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310), cone beam computed tomography (CT) capture 
and interpretation with field of view of both jaws; with or without cranium (D0367), coronectomy-intentional 
partial tooth removal (D7251), therapeutic parenteral drugs, two or more administrations, different medications 
(D9612), collection and application of autologous blood concentrate products (D7921), deep sedation/general 
anesthesia-first 15 minutes (D9222), and the deep sedation/general anesthesia-each subsequent 15 minute 
increment (D9223) provided on October 31, 2022 and November 9, 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 these services are not covered 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 services provided are not among 
those covered under this benefit. Additionally, anesthesia is only covered when rendered with covered 
procedures. Therefore, we decided that the Plan does not have to pay for the consultation-diagnostic service 
provided by a dentist or physician other than requesting dentist or physician (D9310), cone beam computed 
tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367), 
coronectomy-intentional partial tooth removal (D7251), therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), collection and application of autologous blood concentrate 
products (D7921), deep sedation/general anesthesia-first 15 minutes (D9222), and the deep sedation/general 
anesthesia-each subsequent 15 minute increment (D9223) provided on October 31, 2022 and November 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on December 8, 2022. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you pay a $0 copay up 
to the $1,000 allowance for all covered dental services. You pay 100% of the charges beyond the $1,000 
allowance or if you exceed a service limit.  
 
You have been asked to pay $122 for the dental extraction provided. The record shows your benefit for the 
services provided was exhausted on date of service December 8, 2022. Specifically, on this day you received 
six dental extractions which were paid for by the Plan in the amount of $1,000. This is the maximum allowable 
benefit for these services.  The Plan contract states that you must pay 100% of the charges beyond the $1,000 allowance. You have been 
asked to pay the remaining balance 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 cost share for the 
extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on 
December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) machine and humidifier provided on May 12, 2022, to October 12, 2022. 
 
You asked the Plan to waive the coinsurance for a CPAP machine and humidifier. You say that you are 
questioning the continuing payments for a CPAP machine and humidifier. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for the CPAP machine and humidifier provided from May 12, 
2022, to October 12, 2022, as shown below. 
 
 
 Date of Service Item Allowed Amount 20% Coinsurance 
May 12, 2022 Humidifier $18.58 $3.72 
May 12, 2022 CPAP $61.39 $12.28 
June 12, 2022 CPAP $61.39 $12.28 
June 12, 2022 Humidifier $18.58 $3.72 
July 12, 2022 CPAP $61.39 $12.28 
July 12, 2022 Humidifier $18.58 $3.72 
August 12, 2022 CPAP $46.04 $9.21 
August 12, 2022 Humidifier $18.58 $3.72 
September 12, 2022 CPAP $46.04 $9.21 
September 12, 2022 Humidifier $18.58 $3.72 
October 12, 2022 CPAP $46.04 $9.21 
October 12, 2022 Humidifier $18.58 $3.72 
 
This item/service falls within the in-network durable medical equipment (DME) 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 a continuous positive airway pressure (CPAP) machine and 
humidifier provided on May 12, 2022, to October 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 14, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that your doctor is requesting the CGM because you are 
not able to continue pricking your finger because it hurts. The Plan denied your request. The Plan says you do 
not require insulin three or more times daily. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
service is not medically necessary. 
 Our physician reviewer found although the CGM would likely help, coverage has not been met for approval. 
You currently take Lantus once daily and have been advised not to change the dose. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services (81479) provided to the enrollee on August 25, 2022.
You asked the Plan to pay this claim as billed. 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. The Plan requested a reopen and stated that Maximus did not apply the billing criteria included in
the case file and provided a copy of the claim also billing codes to the same specimen. The Plan demonstrated
that the enrollee was billed for this testing on two separate claims.
One claim with code 81479-59 and the other with multiple codes all taken from one specimen. This is not
allowed by Medicare. The expectation is one claim, from samples taken from one specimen when this type of
genetic testing is being performed.
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, this claim could not be paid as billed due to prior claims being billed for
the same specimen and the same form of testing. Medicare rules for coverage of this claim as billed have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided to the
enrollee on August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 27, 
2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for inpatient hospital care. 
 
You have been asked to pay a $75 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care provided on July 27, 2022, to July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit, and an 
outpatient surgery provided October 18, 2022, to December 8, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit and an outpatient surgery. You say 
that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment and a $300 copayment for outpatient surgery/hospital visits/surgical center visits.  
 
You have been asked to pay a $300 copayment and a $300 copayment for an outpatient hospital visit and an 
outpatient surgery. The total amount you are being asked to pay for the services rendered $600 ($300 + $300 = 
$600). This item/service falls within the outpatient surgery/hospital visits/surgical center 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 an outpatient hospital visit, and an outpatient 
surgery provided October 18, 2022, to December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 25, 2022, billed with 
code 81314. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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 code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. (Codes 81162, 81292, 81351, 81201, 81295, 81317, 81298, 81321, 81437, 81307, 81334, 81479, 
81406, 81209, and 81218 were also billed on the claim). Based on this information, we decided that Medicare 
rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on August 25, 2022, billed with code 81314.