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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 04, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $35 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on November 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the computer assisted navigation (0054T) provided on March
25, 2022.
You asked the Plan to pay for the computer assisted navigation. You say that these services were medically
necessary. The Plan denied your request. The Plan says that you have not responded to their request for
records. Maximus overturned the Plan's denial. The Plan requested a reopening based on the fact records were
not provided.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of the computer assisted navigation have
been met. Specifically, the Plan has provided documentation showing they have requested medical records
multiple times without response. Without the missing medical records, the Plan and our office are unable to
determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to
pay for the computer assisted navigation (0054T) provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing home visit provided on August 09, 2022. 
 
You asked the Plan to pay for a nursing home visit. You say that this was medically necessary and should be 
covered. The facility is in control of all paperwork and verification. 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 a nursing home visit 
provided on August 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 06, 2022, to June 16, 2022. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on April 06, 2022, to June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 16, 2022. 
 
You asked the Plan to pay for a telehealth 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 a telehealth visit 
provided on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (0037U) provided to the enrollee on
March 23, 2022.
You asked the Plan to pay for the genetic testing. You say that this was medically necessary. The Plan denied
your request. The Plan says that the date of service should be the date the specimen was collected.
The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS)
policy for either a clinical laboratory test or the technical component of physician pathology service is to bill
the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan
requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of
service on the claim form. The claim shows a Place of Service as an independent laboratory. The rules state
that the date of service submitted on the claim form must be the date the specimen was collected if the
specimen was collected in a laboratory. The specimen was collected on March 1, 2022, but the date of service
on the claim form was March 23, 2022.
We looked at the file and Medicare rules. 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 (0037U) provided to the enrollee on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that proton beam therapy will be considered medically 
reasonable and necessary for the certain conditions. 
 
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 proton treatment delivery. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the case file mentions erective 
difficulty as a rationale for the need for proton therapy but to date, the data do not show that proton therapy 
reduces risks of erective difficulty. It also mentions his history of inguinal hernia repair as a rationale for the 
need for proton therapy, which is not unsupported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 16, 2022. 
 
You asked the Plan to pay for home health services. 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 home health services 
provided on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service January 17, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network podiatry services provided 
on March 16, 2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for out-of-network podiatry services. 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 $50 
copayment per visit for out-of-network podiatry services.  
 
You have been asked to pay a $50 copayment per visit for out-of-network podiatry services. This item/service 
falls within the out-of-network podiatry services benefit category. The total allowed amount for the podiatry 
services is $150 ($50 x 3 visits = $150). However, you are only being $114.56 ($38.25 + $38.25 + $38.06 = 
$114.56) which is less than the required amount. 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 
out-of-network podiatry services provided on March 16, 2022, to September 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to
February 21, 2022.
You asked the Plan to pay for the home health services as billed. You say that you have mailed in the NOA
four times and faxed it once. The Plan denied your request. The Plan says the claim has not been billed with the
correct admission date.
The Plan follows Medicare rules. The rules say that for home health services a NOA must be submitted for the
first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must
report this new date as the admission date in order for the claim to be matched to the correct NOA.
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we
decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to
February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93319 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 93319. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 0 for CPT code(s) 93319. This means 
this is a code that describes physician services. In this case, code 93319 has been billed incorrectly. Based on 
this information, we decided that Medicare rules for coverage of procedure code 93319 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93319 billed for date of service 
April 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on September 21, 
2022, to November 10, 2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on September 21, 2022, to November 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the gastric emptying imaging study 
provided on November 28, 2022. 
 
You asked the Plan to reduce the copayment for the gastric emptying imaging study. You say that you were 
told multiple times the procedure would only have a $250 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 $380 
copayment for nuclear medicine services in an outpatient hospital.  
 
You have been asked to pay $378.58, which is less than the standard $380 copayment for the gastric emptying 
imaging study. This item/service falls within the outpatient diagnostic tests and therapeutic services 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 the gastric emptying imaging study provided 
on November 28, 2022.  Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations provided on September 19, 2022. 
 
You asked the Plan to pay for immunizations. 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 immunizations provided 
on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 28, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
November 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care (99217) provided on July 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 99217 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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])". 
 
We asked our coder 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 services. Our reviewer says that the use of code 99217 is 
not supported by the records provided. Our reviewer found that the records submitted do not contain orders 
confirming what the enrollee's status was at the time of discharge. There is not enough information to 
determine if code 99217 is the correct code to use for the discharge day services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the observation care (99217) provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this claim should be paid. The Plan denied 
your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 procedure code 81345 billed for date of service March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a partial lower denture provided on May 3, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you were told you could get new dentures 
because your prior dentures were messed up. The Plan denied your request. The Plan says your annual dental 
benefit for the year 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. On March 
31, 2022, the Plan paid $61.70 for dental services. On April 1, 2022, the Plan paid $157.81 for dental services. 
On May 16, 2022, the Plan paid $179.36 for dental services. On May 3, 2022, the Plan paid $1,601.13 for 
dental services. For the year of 2022 the Plan paid $2,000 ($61.70 paid + $157.81 paid + $179.36 paid + 
$1,601.13 paid) for dental services. The record shows your annual dental benefit for the year was exhausted on 
the date of service of May 3, 2022. Therefore, we decided that the Plan does not have to pay more for a partial 
lower denture provided on May 3, 2022.