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

 
We decided that the Plan does not have to pay for cone beam computed tomography (CT) capture and 
interpretation, limited (D0364) provided on September 14, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that this service was necessary to determine 
treatment options. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam computed tomography (CT) capture and interpretation, limited (D0364) provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 4, 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 medical necessity. The Plan requested a reopen and stated the issue was not medical necessity but the fact that the claim was not billed appropriately. The Plan noted that the Medicare billing criteria were not met.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules state the date of service for a clinical laboratory test, or the technical component of physician pathology service must be the date the specimen was collected. The medical records provided show the collection date was June 4, 2021, however, the date the specimen was received was June 7, 2021. The billed date versus the specimen collection dates do not meet the required criteria. 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 June 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 01, 2022, 
to July 11, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible to 
pay this. 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 $140 
copayment for physical therapy. 
 
You have been asked to pay a $140 copayment for physical therapy. This item/service falls within the physical 
therapy 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 physical therapy provided 
on July 01, 2022, to July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit provided on August 17, 2022. 
 
You asked the Plan to pay for outpatient office visit. 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 outpatient office visit 
provided on August 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services to be 
provided out-of-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on May 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 2022.
You asked the Plan to pay for this testing. You say that these services should be paid by the Plan. The Plan denied your request.
The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan noted that Medicare Guidance states the date of service for a clinical laboratory test, or the technical component of physician pathology service must be the date the specimen was collected. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date of service of the test or service must be the date the specimen was obtained from storage. The testing billed with a date of service inconsistent with Medicare rules governing laboratory services. The clinical records show that a specimen was collected on February 27, 2018, rather than the billed date of service April 4, 2022. There is no documentation to support genetic testing on the billed date of service. The Plan notes the requisition was signed on March 22, 2022, and Tempus reported receiving the specimen on March 26, 2022. The specific date that the test was obtained from storage is not identified. Therefore, the appropriate date of service per Medicare rules would fall between the date the test was ordered (March 22, 2022), and the test was received (March 26, 2022).
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case this claim could not be paid as billed due to a discrepancy with the date of service billed and the date of specimen collection. Medicare rules for coverage of this claim were not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive evaluation (D0150) and an adult 
prophylaxis (D1110) provided on January 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to this provider for a cleaning, and it 
was not very good. You also say you went back to your primary dental provider. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive evaluation (D0150) and an adult 
prophylaxis (D1110) provided on January 4, 2022.  
 Your complaint about this provider potentially ordering services that are not needed 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 procedure code 99100 billed for date of service March 30, 2022.
You asked the Plan to pay for procedure code 99100. You say that for code 99100, this fee is in addition to the primary anesthesia procedure and is separately payable based on "ASA guidelines." The Plan denied your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code.
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on January 16, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the services are payable per CMS guidelines. 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 x-rays provided on 
January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 17, 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. The Plan notes that the enrollee was an inpatient from February 16, 2022, to April 29, 2022. The specimen was taken on March 8, 2022, during the inpatient stay and sent to the lab by the inpatient facility. Payment for laboratory services is inclusive in the diagnosis related group (DRG) payment to the acute care hospital. Payment to you for these services is the responsibility of the facility who forwarded the specimen.
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, payment for these services was included in the inpatient claim submitted by the facility. Payment to you for this service should be submitted to the facility, not the Plan. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided from May 27, 2021, to June 27, 2022.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you should not be responsible for this coinsurance. 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the oxygen equipment. This item/service falls within the durable medical equipment (DME) and related supplies 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 the oxygen equipment provided from May 27, 2021, to June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab services provided on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was medically necessary. The Plan denied your request. The Plan says 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 the medical records show you did not require an inpatient level of care to include three hours of therapy per day at least five days per week.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. IRF admission being "beneficial" is not of issue. Enrollees must meet the required criteria prior to entry of the IRF to be covered by Medicare.
At the time of the appeal, Medicare rules for coverage of IRF care were not met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches for the enrollee.
You asked the Plan to provide coverage for this treatment. You say that at the time of the appeal, this treatment was medically necessary for the enrollee. 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.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches. The Maximus Physician Reviewer determined that the services were medically necessary. The Plan requested a reopen and stated that Maximus reviewed the wrong service. The Plan states there is no documentation of why the enrollee is not a candidate for radiofrequency ablation (RFA) (such as established spinal pseudarthrosis, implanted electrical device). The Plan notes that based on the medical records and LCD L33930 criteria, medial branch blocks at the same location as the previously successful RFA procedure are not medically reasonable and necessary. However, another RFA procedure at the same location as the previously successful RFA would be considered medically reasonable and necessary, based on LCD L33930 criteria. The medical records show the enrollee was a then 70-year-old woman with a diagnosis of Spondylosis without myelopathy or radiculopathy, lumbar region. The enrollee underwent left L4-S1 facet joint ablation with radiofrequency on December 28, 2021. On January 25, 2022, the enrollee reported 80% relief for a week, but then the pain started to increase. On August 10, 2022, the enrollee reported 5/10 low back pain. The plan included lumbar Medial Branch Block (MBB). The appeal submitted on September 7, 2022, was for left lumbar facet joint nerve block. The Plan is correct in this case. LCD L33930 states that MBB at the same level as a previously successful RFA procedure is not considered medically reasonable and 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 this treatment have not been met. Therefore, we decided that the Plan does not have to provide coverage for Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the massage therapy services provided between October 10, 2021, and December 19, 2021
You asked the Plan to pay for the massage therapy services. You say that you were told you could have an extension. The Plan denied your request. The Plan says that your request for reimbursement was not submitted within 60 days of the end of the 2021 plan year.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The Plan has additional benefits that cover massage therapy services. The Plan also requires you to submit your claim within 60 days of the date you received the service or item and no later than 60 days after the end of the Plan year. Your claim was not submitted until March 21, 2022, which is more than 60 days after the end of the 2021 Plan year. Therefore, we decided that the Plan does not have to pay for the massage therapy services provided between October 10, 2021, and December 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam provided on July 08, 2022. 
 
You asked the Plan to pay for tissue exam. 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 tissue exam provided on 
July 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 17, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you were told that you 
would only owe a $25 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 $115 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $115 copayment for outpatient diagnostic tests. However, you are only being 
asked $87.89 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic 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 waive 
the copayment for outpatient diagnostic tests provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous passive motion device (E0936), provided on 
October 5, 2022. 
 
You asked the Plan to pay for the continuous passive motion device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
Covered for patients who have received a total knee replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous passive motion device have not been met. Specifically, you did not have a total 
knee replacement. Therefore, we decided that the Plan does not have to pay for the continuous passive motion 
device (E0936), provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP and supplies provided on August 
12, 2022. 
 
You asked the Plan to waive the coinsurance for CPAP and supplies. You say that you did not know you had to 
pay a 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for CPAP and supplies. This item/service falls within the durable 
medical equipment (DME) and related supplies 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 CPAP and supplies provided on August 12, 2022.