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

 
We decided that the Plan does not have to pay for neurological testing provided on April 19, 2022, billed with 
codes 95822 and 95927. 
 
You asked the Plan to pay for neurological testing. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 95927 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; 95822 is electroencephalogram (EEG) recording in coma or sleep only. 
 
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 neurological testing. Our reviewer says that the 
somatosensory evoked potentials (SSEP) testing is not shown to have been performed. Our reviewer found the 
electroencephalogram (EEG) services were performed during intracranial surgery for which there is a more 
appropriate CPT code.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurological testing have not been met. Therefore, we decided that the Plan 
does not have to pay for neurological testing provided on April 19, 2022, billed with codes 95822 and 95927.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital hearing aid (V5261) provided on September 20, 
2022. 
 
You asked the Plan to pay for a digital hearing aid (V5261). You say that you called the plan twice and were 
assured you would receive $2,000 for each ear's hearing aid. The Plan denied your request. The Plan says the 
services were not provided by the preferred network providers. 
 
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 the enrollee selects the hearing aid from the list of available devices.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a digital hearing aid (V5261) have not been met. Therefore, we decided that the Plan does not have 
to pay for a digital hearing aid (V5261) provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth service provided on December 20, 2022. 
 
You asked the Plan to pay for a telehealth service. You say that the patient was in a facility at the time of this 
visit, please reconsider. 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 service 
provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367), bone replacement graft (D4263), surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), abutment supported porcelain/ceramic crown (D6058), 
provisional implant crown (D6085), and problem focused limited oral evaluation (D0140) provided from June 
20, 2022, to November 17, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, bone replacement graft, endosteal 
implant, custom fabricated abutment, abutment supported porcelain/ceramic crown, provisional implant crown, 
and problem focused limited oral evaluation. You say that discuss surgery on gums should be filed under 
medical claims. The Plan denied your request. The Plan says the cone beam CT capture and interpretation, 
bone replacement graft, endosteal implant, custom fabricated abutment, abutment supported porcelain/ceramic 
crown, and provisional implant crown are not covered expenses under your Dental plan. The Plan also says that 
your benefits for the problem focused limited oral evaluation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT capture and 
interpretation, bone replacement graft, endosteal implant, custom fabricated abutment, abutment supported 
porcelain/ceramic crown, and provisional implant crown are not among those covered under this benefit. The 
contract also clearly states that periodic oral exams and emergency diagnostic exams share a frequency 
limitation of 2 procedure codes per calendar year. The record shows that you received a periodic oral 
evaluation (D0120) on February 22, 2022, and a problem focused limited oral evaluation (D0140) on March 
23, 2022, and your periodic oral exams and emergency diagnostic exams benefit had been exhausted. 
Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) 
capture and interpretation (D0367), bone replacement graft (D4263), surgical placement of implant body: 
endosteal implant (D6010), custom fabricated abutment (D6057), abutment supported porcelain/ceramic crown 
(D6058), provisional implant crown (D6085), and problem focused limited oral evaluation (D0140) provided 
from June 20, 2022, to November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81400, 81286, 81185, and 81413) provided to the enrollee on June 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information.
The Plan demonstrated that this claim denied because the provider is billing an additional code on the same date of service which includes this code. Code 81286-XU, 81400 and 81479 were denied per the Medicare Billing and Coding: Molecular Pathology and Genetic Testing (A58917) that explains, "If the laboratory method is NGS testing, and the laboratory assays two (2) or more genes in a patient in parallel, then those two (2) or more genes will be considered part of the same panel, consistent with the NCCI manual Chapter 10, Section F, number 8." In addition, the records do not contain documentation of the duplication/deletion gene analysis of at least 2 genes, including KCNH2 and KCQ1, to support the coding criteria 81414-XU. The records also do not contain documentation of the sequencing of the SOS1 gene to support the coding criteria for 81442.
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 could not be paid as billed due to the bundled relationship between the codes billed on the claim and the lack of medical records to support the diagnosis. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81400, 81286, 81185, and 81413) provided to the enrollee on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 laboratory services 
provided on October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services under code 20931 provided 
on May 20, 2022. 
 
You asked the Plan to pay for procedure code 20931. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20931. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for procedure code 20931 have not been met. Therefore, we decided that the Plan does not have to pay for the 
assistant at surgery services under code 20931 provided on May 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110 and 97530 billed for May 2, 2022, to 
May 16, 2022. 
 
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 procedure codes 97110 and 97530 are not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities 
to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97110 and 97530 are not supported in the medical record. Specifically, there is no 
documentation of time spent on the individual service for therapeutic procedure to one or more areas for each 
15 minutes to support code 97110. There is no documentation of time spent on therapeutic activities, direct 
patient contact, for each 15 minutes to support code 97530. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97110 and 97530 billed for May 2, 2022, to May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for root canal therapy (D3310) provided on August 31, 2022. 
 
You asked the Plan to pay for the root canal therapy. You say that you went to an in-network dental group, but 
the dentist you saw was not a network provider. The Plan says the claim reprocessed to apply the in-network 
benefit of 50% coinsurance for root canal 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 50% of the 
cost for root canal services from an in-network provider. Therefore, we decided that the Plan does not have to pay 
more for root canal therapy (D3310) provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0483) provided to the enrollee on October 19, 2021.
You asked the Plan to pay for the drug testing. You say that you have provided the laboratory reports to support the service billed. The Plan denied your request. The Plan says that the documentation provided does not support the service 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. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the test results submitted do not include more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing (G0483) provided to the enrollee on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 21, 2022.
You asked the Plan to pay for the drug testing. You say that you are being forced to pay for services for which you should not be responsible. The Plan denied your request. The Plan says that the records do not include definitive laboratory results for 22 or more drug classes to support the coding criteria for the code billed on date of service.
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 G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the test results submitted do not include more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
scan provided on October 19, 2022. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) scan. You say that 
you were not informed there would be a copayment for this service. 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 
$112.44 copayment for Medicare-covered outpatient facility for diagnostic radiology services. 
 
You have been asked to pay a $112.44 copayment for an in-network computed tomography (CT) scan. This 
item/service falls within the Medicare-covered outpatient facility for diagnostic radiology 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. You have been 
asked to pay the allowed amount of $112.44 which is less than the $175 copayment for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
scan provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an amalgam, periodontal scaling and root planing, 
extraction, and general anesthesia/deep sedation (D4342, D2140, D9215, D7210) provided on September 6, 
2022, to October 4, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for general anesthesia/deep sedation (D9215) denied correctly as they do not fall within 
your dental 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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for an amalgam, periodontal scaling and root 
planing, extraction, and general anesthesia/deep sedation (D4342, D2140, D9215, D7210) provided on 
September 6, 2022, to October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit, a medical eye examination, and 
fundus photography provided on September 09, 2022, to September 15, 2022. 
 
You asked the Plan to pay for a specialist office visit, a medical eye examination, and fundus photography. You 
say that you have been to this doctor before without asking for any authorizations. You also say that you could 
only assume it would hold true again. 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 specialist office visit, a 
medical eye examination, and fundus photography provided on September 09, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care visit provided on December 17, 2021. 
 
You asked the Plan to pay for wound care 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 wound care visit 
provided on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a stage IA3 non-small 
cell lung cancer(NSCLC) diagnosed in June of 2021. Tecentriq as a single agent or in combination is not 
approved by the Food and Drug Administration (FDA) for the treatment of recurrent NSCLC in the second line 
setting with prior treatment with immunotherapy. The use is not supported by the major drug compendia or the 
medical literature. Tecentriq is not safe and effective or reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tecentriq.