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

 
We decided that the Plan does not have to pay for ambulance services provided on April 26, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was timely filed and includes all 
of the needed documentation to be processed for payment. The Plan denied your request. The Plan says it is not 
responsible for this bill because the patient was on hospice on the date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination provided on February 2, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiologic examination. You say that the service was medically necessary, 
and the enrollee could not choose which radiologist reads their diagnostic tests. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
radiologic examination. We found no exception that would require the Plan to pay for the radiologic 
examination. The records provided for review do not show that radiologic examination was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the radiologic examination provided on February 
2, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
December 7, 2021. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the medical records support 
coverage of these services. The Plan denied your request. The Plan says no separate payment is made for these 
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.  
We find that CPT codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 20930 and 20936 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service December 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 24, 2022 to 
January 26, 2022 by an out-of-network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
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 the nursing facility care provided on January 24, 
2022 to January 26, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac rehabilitation-monitor provided on October 6, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for cardiac rehabilitation-monitor. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 cardiac rehabilitation-monitor at issue in this appeal. The Plan did not 
pre-approve the cardiac rehabilitation-monitor 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 cardiac rehabilitation-
monitor provided on October 6, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 3, 2021 to January 9, 2021. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim submitted was missing required elements. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
G and Q codes for the home health services were not included on the claim. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from January 3, 2021 to January 
9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 3, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service February 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on August 26, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic treatment. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 chiropractic treatment at issue in this appeal. The Plan did not pre-
approve the chiropractic treatment 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 chiropractic treatment provided on 
August 26, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies rendered on November 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 the diabetic testing supplies rendered on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service January 11, 
2022. 
 You asked the Plan to pay for procedure code 71260. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71260 is bundled into payment for 
code 75572. 
 
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 71260 
is a column II code to column I code 75572. 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 71260 billed for date of service January 11, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile imaging services rendered on December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the mobile imaging services 
rendered on December 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in-person programmable device evaluation (93281) 
provided on May 13, 2021. 
 
You asked the Plan to pay for the physician service. You say that the service is not related to the enrollee's 
hospice diagnosis and therefore should be covered. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the in-person programmable device evaluation (93281) 
provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) 
vaccine rendered on October 19, 2021. 
 
You asked the Plan to pay for these services. You say that you have a newborn grandchild coming and the 
doctor advised the shot would protect the baby. The Plan denied your request. The Plan says the services are 
not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis 
(TDaP) vaccine rendered on October 19, 2021.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD) facility services (90999) 
provided December 10, 2020 to December 31, 2020. 
 
You asked the Plan to pay for the ESRD facility services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90999 is not supported in the medical record. Specifically, a required modifier (G) for 
the ESRD facility services was not included. Based on this information, we decided that Medicare rules for 
coverage of the ESRD facility services have not been met. Therefore, we decided that the Plan does not have to 
pay for end-stage renal disease (ESRD) facility services (90999) provided December 10, 2020 to December 31, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), full mouth x-rays 
(D0210), and periodontal scaling and root planing in all four quadrants (D4341) provided on February 21, 2022. 
 
You asked the Plan to pay for an evaluation, x-rays, and periodontal scaling. You say that any preventive care 
should be covered when a new provider is needed due to changes in the new policy coverages. The Plan denied 
your request. The Plan says periodontal scaling (D4341) is not covered by your supplemental dental benefits. A 
comprehensive oral evaluation (D0150) is covered once every three years. A full mouth x-ray (D0210) is 
covered once every five years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation (D0150) once every three years and a full mouth x-ray (D0210) once every five 
years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal scaling is not among those 
covered under this benefit. We looked at this case file, the Plan's rules, and Medicare rules. The record shows 
the Plan paid for a comprehensive oral evaluation and full mouth x-rays provided on June 10, 2020; therefore, 
the benefit for a comprehensive oral evaluation and full mouth x-ray has been exhausted. We decided that the 
Plan does not have to pay for a comprehensive oral evaluation (D0150), full mouth x-rays (D0210), and 
periodontal scaling and root planing in all four quadrants (D4341) provided on February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation (99253) provided on November 30, 
2021. 
 
You asked the Plan to pay for an inpatient consultation. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this service was billed with a code that is not valid 
for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of an inpatient consultation have not been met. Therefore, we decided that the Plan does not have to 
pay for an inpatient consultation (99253) provided on November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility
services were medically necessary. The Plan denied your request. The Plan says at the time of the appeal
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 Medicare criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services. The
Maximus Physician Reviewer determined that the enrollee had daily skilled therapy needs that required the
specialized skill, knowledge, and SNF services were reasonable and necessary. The Plan requested a reopen
and argued that at the time of the appeal you were not yet ready to be transferred to SNF level of care, and that
it was still necessary for you to remain in the inpatient hospital setting at the time.
The medical records show that at the time of the appeal you had a history of cardiomyopathy, atrial fibrillation,
hypertension, and recent Covid-19 infection. You were admitted to the acute care hospital with abdominal pain
and diarrhea. A chest X-ray on March 8, 2022, suggested pulmonary edema and you were given IV diuretics. It
is documented that you still had significant shortness of breath and edema even with this treatment. The Plan is
correct in this case. The documentation does not support that at as of March 10, 2022, you were stable for
discharge from an inpatient hospital level of care to a SNF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 18, 20, and 22. 
 
You asked the Plan to pre-approve the crowns. You say that you would like these crowns to be approved for 
coverage because you are suffering from toothaches and pain. The Plan denied your request. The Plan says the 
crowns are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 the crowns. Our reviewer says that the 
documentation provided does not meet the criteria of medically reasonable and necessary for coverage for 
crowns for tooth #'s 18, 20, and 22. Our physician reviewer found the reason for the Plan's denial was that the 
service is not medically reasonable due to the severe bone loss and poor prognosis for retention of these teeth. 
Our reviewer also found that a review of the documentation provided corroborates the poor prognosis due to 
severe bone loss.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #'s 18, 20, and 22.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you need SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the medical records do not 
document that you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (dental code 
D1206) and filling (dental code D2330) for tooth #24, #25, and #26 provided on February 9, 2022, and 
February 23, 2022. 
  You asked the Plan to pay for the topical application of fluoride varnish and filling. You say that you were told 
by the Plan that the dentist was approved, and you would like your bills paid. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because these services are not covered by the 
Plan's dental benefits, or they are covered but the coverage 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. The Plan covers 1 filling code 
per calendar year. The Plan does not cover topical application of fluoride varnish. 
 
We looked at this the file, the Plans rules, and Medicare rules. You previously received a filling on tooth #23 
on February 23, 2022; therefore, the benefits for the rest of the service were exhausted on the same date of 
service of February 23, 2022. Additionally, topical application of fluoride varnish is not covered by the Plan. 
Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (dental 
code D1206) and filling (dental code D2330) for tooth #24, #25, and #26 provided on February 9, 2022, and 
February 23, 2022.