Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home covid-19 test, purchased on January 18, 2022. 
 
You asked the Plan to pay for the at home covid-19 test. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at home covid-19 test have not been met. 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for the at home covid-19 test, purchased on January 
18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services (29881, 29874), provided on 
October 29, 2021. 
 
You asked the Plan to pay for the assistant surgeon services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says Medicare does not pay for these services when provided by a 
RNFA. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
(29881, 29874), provided on October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Synvisc-One. Our reviewer says that 
the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of bilateral primary osteoarthritis of the knees. In this case, the Plan requires a trial of Euflexxa, 
Durolane, Supartz-FX, and Gelsyn-3 before they will approve the requested drug. The case file does not 
contain documentation of trial and failure of Euflexxa, Durolane, Supartz-FX, and Gelsyn-3. In addition, the 
documentation does not support that Euflexxa, Durolane, Supartz-FX, and Gelsyn-3 would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment delivery and set up (A9901) 
provided on January 24, 2022. 
 
You asked the Plan to pay for durable medical equipment delivery and set up. You say that you would like this 
claim reprocessed for payment. The Plan denied your request. The Plan says this is not in the statutory 
definition of physician services for fee schedule payment purposes. 
 
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 A9901 is durable medical equipment delivery, set up, 
and/or dispensing service component of another Healthcare Common Procedure Coding System code. 
 
We looked at the file and Medicare rules. In this case, code A9901 has a Status Code of X under the 
Physician Fee Schedule. This Status Code indicates that this code is not in the statutory definition of physician 
services for fee schedule payment purposes. No payment for this code will be made per Medicare rules. Based 
on this information, we decided that Medicare rules for coverage of durable medical equipment delivery and set 
up have not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
delivery and set up (A9901) provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81206, 81235, and 81321 provided 
on May 23, 2021. 
 
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 are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, if a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code should be submitted for the 
panel. One code was not submitted for the entire panel. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing coded 81206, 81235, and 81321 provided on May 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on December 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel detects certain genomic alterations. 
The Plan denied your request. The Plan says the testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We looked at the file and the rules. We find that the gene panel 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 have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that you meet the requirements for the payment of 
the bill. The Plan denied your request. The Plan says the new patient code is not allowed. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99203 is not supported. The records show that you 
were seen by the provider at issue on June 3, 2021. This means that a new patient visit is unable to be billed. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on 
February 17, 2022. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that you disagree with the 
plan's decision. The Plan denied your request. The Plan says the claim has been processed correctly per the 
enrollee's plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $1300 deductible out of pocket before the Plan will pay their share for your covered services.  
 
 
 
 Review of the file shows that the provider is out of network with the Plan. This makes the laboratory services 
fall within the deductible benefit category. The enrollee has been asked to pay $970.76 deductible for the 
laboratory services. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services 
provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 11, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the code at issue was not billed with a modifier suitable for 
payment. 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 physician services provided on 
February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that at the time of the appeal, these services were
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial for a lack of notice of non-coverage in the file. The Plan requested a
reopen and submitted the required notice.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued SNF
services. The records show a history of hypertension and chronic kidney disease. You suffered a stroke,
resulting in right-sided weakness. On June 1, 2022, you were reported to be safe to walk with nursing and to
transfer with nursing. You were scheduled to be discharged home on June 3, 2022, with home health nursing
and physical therapy services. Your family appealed the discharge. On June 6, 2022, you had been in the SNF
for twenty days. The occupational therapy re-evaluation documents that you made steady gains with self-care
performance. There were no changes in functional mobility. At that point, no daily skilled nursing services
were required, and the documentation did not support that SNF services were medically reasonable and
necessary on an inpatient basis and daily, after 6/2/22.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the resin-based composite filling rendered on December 27, 2021. 
 
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 that you exceeded the benefit limit for these services. 
 
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 non-Medicare 
covered comprehensive dental services. 
 
We looked at the file and the Plan's rules. The Plan states that the services exceeded the benefit limit; however, 
the Plan contract does not clearly state that there is a benefit limit for fillings. The Plan has not provided any 
documentation to support that the services are not covered. Therefore, we decided that the Plan has to pay for 
the resin-based composite filling rendered on December 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 30, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says the drug testing was approved, but the specimen 
validity testing cannot be separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 30, 2021, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a house/extended care facility call (D9410) provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve a house/extended care facility call. You say that you would like the Plan to 
approve D9410. The Plan denied your request. The Plan says D9410 is not a covered dental benefit. 
 
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 pre-approve a 
house/extended care facility call (D9410) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and prefabricated 
post and core in addition to crown (D2954) provided January 10, 2022. 
 
You asked the Plan to pay for the crown and prefabricated post and core. You say that it was not your fault the 
dentist had to replace the tooth. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for these services. 
 
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 crown and 
prefabricated post and core once every 84 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a crown was 
previously covered on October 11, 2017. Based on this information, we decided that the Plan's frequency limit 
for coverage of the crown and prefabricated post and core has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the crown - porcelain/ceramic (D2740) and prefabricated post and core in 
addition to crown (D2954) provided January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis surgery. 
 
You asked the Plan to pre-approve spine surgery. You say that the enrollee needs this procedure or will be 
hospitalized. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the records do not show the indications for this surgery. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not include any physical examinations and/or diagnostic imaging 
studies. There is no evidence of any instability or potential impending/inevitable temporary intra-operative 
instability. Detailed evidence of severe and/or progressive neurological abnormalities has not been 
documented. The requested level for the procedure is not clearly documented. There is no compelling rationale 
or extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, monaural, behind the ear (V5257) 
provided June 28, 2021, and the hearing aid rental (V5299) provided September 30, 2021. 
 
You asked the Plan to pay for the hearing aid and hearing aid rental. You say that you needed new hearing aids 
because the provider created your hearing aids based on a past hearing test. You say you followed the plan's 
expectations and rules, and the purchases and rentals should be covered. The Plan denied your request. The 
Plan says the type of hearing aid purchased is not covered under your benefits. Additionally, hearing aid rentals 
are not covered under your benefits.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you purchase private label Basic or Reserve level hearing aids. 
 
We looked at the file and the Plan's rules. In this case the hearing aids purchased are not Basic or Reserve level 
hearing aids. Though the Plan offers hearing benefits in excess of Medicare coverage, the hearing aid rental is 
not among those covered services. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aid and hearing aid rental have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid, digital, monaural, behind the ear (V5257) provided June 28, 2021, and the hearing aid 
rental (V5299) provided September 30, 2021.  
 Please note that the Plan has provided documentation showing that they have reached out to the hearing 
provider to review your concerns. You may reach out to the Plan if you have questions or concerns about the 
provider and the Plans response to these concerns.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95868 provided 
on December 8, 2021. 
 
You asked the Plan to pay for the needle electromyography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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, we have confirmed that code 95868 
is a column II code to column I code 95865. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the needle electromyography services coded 95868 provided on 
December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2391) provided on 
January 25, 2022. 
 
You asked the Plan to pay more for the resin-based composite. You say that your insurance has always covered 
cavities one at a time and every single time you have paid a copayment and had no issue after that. The Plan 
denied your request. The Plan says benefits have been paid on the least costly method of treatment. The Plan 
also says that you are responsible for the remaining balance plus the difference between the allowed amounts. 
 
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 contract says that if the Plan 
determines an alternate treatment will produce a professionally satisfactory result, the maximum the Plan will 
allow will be the charge for the less expensive treatment. The record shows that the Plan determined an 
amalgam was satisfactory, and paid 80% of the allowed amount for an amalgam (D2140), and you are 
responsible for the remaining 20% of the allowed amount plus the difference in allowed amounts. Therefore, 
we decided that the Plan does not have to pay more for the resin-based composite (D2391) provided on January 
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on September 22, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says the drug testing was approved, however, no payment can 
be made for code 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on September 22, 2021, billed with code 83789.