Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral examination and periodontal scaling and root 
planning provided from September 22, 2022, to October 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are either not a covered benefit under your dental plan or the benefit 
has 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 oral examination was exhausted on dates of service January 26, 2022, and August 
31, 2022. Additionally, periodontal scaling and root planning is not covered under any circumstance. 
Therefore, we decided that the Plan does not have to pay for the oral examination and periodontal scaling and 
root planning provided from September 22, 2022, to October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided on January 24, 2022. 
 
You asked the Plan to pay for diagnostic services. You say that your laboratory received an esophageal biopsy 
specimen obained during an esophagogastroduodenoscopy (EGD) performed on the member. 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 diagnostic services 
provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection does not meet 
the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 an epidural steroid injection have been 
met. Specifically, no medical records were provided for our review. Therefore, we decided that the Plan does 
not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 9, 2022.
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. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan notes this is an administrative determination for billing and is not based on clinical criteria for medical necessity. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service. The specimen was collected during a hospital outpatient encounter. Further, the test has not been cleared or approved by the FDA and is not a companion diagnostic for any therapy
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 due to errors with the POS code and demonstration that this testing was medically appropriate and covered by Medicare. 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 genetic testing provided to the enrollee on April 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided on June 
7, 2022. 
 
You asked the Plan to pay for the medication assisted treatment. The Plan denied your request. The Plan says 
the services were rendered by a provider who is credentialed as a Registered Nurse and is non-participating 
with the Plans network. 
 
The Plan must follow Medicare rules. Medicare rules say that a registered nurse is a type of provider that 
frequently attempts to enroll in Medicare but is not eligible to do so. 
 
We looked at the file and Medicare rules. Specifically, the documentation shows that this service was provided 
by a registered nurse. Based on this information, we decided that Medicare rules for coverage of the medication 
assisted treatment have not been met. Therefore, we decided that the Plan does not have to pay for the 
medication assisted treatment (G2067) provided on June 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
August 16, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not agree 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 $120 
copayment per visit for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency 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 the emergency room visit 
provided on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multianalyte assay procedure with algorithmic analysis 
provided on July 06, 2021. 
 
You asked the Plan to pay for a multianalyte assay procedure with algorithmic analysis. You say that this 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 a multianalyte assay 
procedure with algorithmic analysis provided on July 06, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 09, 2022. 
 
You asked the Plan to pay for chiropractic care. 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 chiropractic care 
provided on September 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on October 06, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were 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 the subsequent nursing 
care provided on October 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate upper denture (D5130) and an immediate 
lower denture (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to reinstate your 
denture benefits so you can get permanent dentures. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 items or services was exhausted on the date of service of April 13, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an immediate upper denture (D5130) and an 
immediate lower denture (D5140).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 9, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations and the date of consultations in the patients medical record. If 
consultation with the attending or primary care physician is unsuccessful, document the patients medical chart 
with the date and manner of notification to the physician. There was no documented contact with the 
attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
10, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that multiple exams were performed on this date 
of service. You say that this claim should be paid. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 10, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening (71271). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Additionally, the rules say that Medicare covers a lung cancer screening counseling and shared 
decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with a LDCT, as an 
additional preventive service benefit under the Medicare program when certain criteria are met. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has indicated that the enrollee does not meet criteria for 
coverage of the requested service as the enrollee quit smoking more than fifteen years ago. However, the record 
indicates that the enrollee is a passive smoker and has been all of her life. The Plan has not substantiated their 
denial in this case; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-
approve a low dose computed tomography (LDCT) scan for lung cancer screening (71271).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 95939 and 95938 provided on March 2, 2022. 
 
You asked the Plan to pay for codes 95939 and 95938. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that there was an invalid diagnosis code on the claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied these codes due to invalid 
diagnosis code on the claim. The Plan did not include an explanation or Medicare rules to support this denial. 
Therefore, the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for codes 
95939 and 95938 provided on March 2, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on March 1, 2022.
You asked the Plan to pay additional reimbursement for these services. The Plan says the $50 benefit was exhausted. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Explanation of Benefits shows the Plan paid $20, plus a 20% discount of $68.80 for these services. The Evidence of Coverage shows a $50 allowance towards the purchase and fitting of eyeglasses, or lenses, or contacts. The records show you owe $155.20 for the eyeglasses correctly and the Plan actually paid over the $50 allowance for this service.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan covers up to $50 for vision services. The records show your costs exceeded this benefit. Therefore, we decided that the Plan does not have to pay for vision services provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for vision services provided on March 31, 2022.
You asked the Plan to pay additional reimbursement for vision services. You say that the Plan should cover more of the cost of these vision services. The Plan denied your request. The Plan states the vision benefit was exhausted. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus has issued an overturn decision stating that the plan must pay $80 more. It has been determined that claim denied because the allowance for this service had been exhausted. The Plan says the Plan contract states enrollees are responsible for any amount over the $200 retail price for the frames and lens package. The Explanation of Benefits shows the Plan $120, and also applied a 20% discount of $183.98 towards this service. In fact, the Plan demonstrated that they paid a total of $303.98 for this service which is more than the $200 benefit allowance.
The Plan is correct in this case. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The maximum Plan benefit is $200.
The documentation shows the Plan has actually paid more than the maximum benefit for these vision services. Therefore, we decided that the Plan does not have to pay additional reimbursement additional reimbursement for vision services provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on September 19, 
2022. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that the provider is in network with 
your Plan. 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 30% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 30% coinsurance for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office 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 coinsurance for an office visit provided on September 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642-26-RT and 76642-26-LT billed for 
date of service October 27, 2022. 
 
You asked the Plan to pay for procedure codes 76642-26-RT and 76642-26-LT. You say that the enrollee had 
multiple exams on this date of service. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed two units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 76642-26-RT and 76642-26-LT have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 76642-26-RT and 76642-26-LT billed for date of service October 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a CT scan for the enrollee.
You asked the Plan to provide coverage for a CT scan. You say that a CT scan is medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes that Maximus decision was favorable based on the rationale that if "MAKO" (robotic assisted) arthroplasty is approved then the CT scan is needed to do the procedure. However, as previously stated, coverage of robot assisted arthroplasty was neither requested by the provider nor approved by the plan.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. In this case a CT scan requested in anticipation of the possibility of a request for future service is not covered by Medicare. MAKO (robotic assisted) arthroplasty had not yet been requested or approved. Therefore, approval of this CT scan was done so in error. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to provide coverage for a computed tomography (CT) scan for the enrollee.