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

 
We decided that the Plan does not have to pay for laboratory services provided on May 16, 2022. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on September 06, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that you are in-network and this should be 
covered. 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 skilled nursing facility 
visit provided on September 06, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on August 22, 2022. 
 
You asked the Plan to pay for a mental health visit. You say that you had a referall from your doctor and you 
were unaware that this provider was out-of-network. 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 mental health visit 
provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the nephrology specialist office visit 
provided on December 9, 2022. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you were sent your 
2023 membership card in December of 2022 and were told you could use it right away. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist office visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
each in-person specialist office visit benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for 
the specialist office visit provided on December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diabetic shoes and the diabetic shoe 
inserts provided on November 19, 2022. 
 
You asked the Plan to waive the cost sharing for the shoes and the inserts. You say that you were not aware of 
the cost sharing for these items. 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, oxygen/oxygen equipment and related supplies.   
 
 
 
 
 You have been asked to pay a $31.12 coinsurance for the shoes ($155.60 allowed amount x .20 = $31.12), and 
a $56.82 coinsurance for the inserts ($284.10 allowed amount x .20 = $56.82). You have been asked to pay a 
total cost share of $87.94 for the shoes and the inserts ($31.12 + $56.82 = $87.94). These items/services fall 
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 cost sharing for the diabetic shoes and the diabetic shoe inserts provided on November 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the regadenoson injection provided by an 
in-network provider on November 8, 2022. 
 
You asked the Plan to reduce the cost sharing for the injection. You say that you think that the cost sharing 
amount for this service is too high. 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 in-network Medicare Part B covered drugs provided at all locations of service. 
 
 
 
 
 You have been asked to pay a $49.08 coinsurance for the injection ($245.40 allowed amount x .20 = $49.08). 
This item/service falls within the Medicare Part B prescription drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the cost sharing for the regadenoson injection provided by an in-network provider on 
November 8, 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 
April 26, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were first sent an 
Explanation of Benefits (EOB) showing a $0 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 $90 
copayment for each in-network or out-of-network emergency room visit.  
 
You have been asked to pay a $90 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 April 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
16, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not order the 
ambulance services and should not have to pay for them. 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 $250 
copayment for each one-way Medicare-covered ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 the ambulance 
services provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that the primary insurer's Explanation of 
Benefits was already attached, so this claim should be paid. The Plan denied your request. The Plan says 
procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection. We decided that the Plan does not have 
to pre-approve a backup camera bracket and backup camera.  
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), backup camera bracket (A9270) and a backup camera (A9270).. You 
say that the services are necessary. The Plan says that based on the documentation provided, coverage criteria 
have not been met. 
 
We decided that the Plan has to pre-approve an electronic connection.  
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met.  
 
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 an electronic connection. Our reviewer 
says that the services are medically necessary. Our physician reviewer found an expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the power 
tilt and recline and power elevating leg rests via a joystick. Therefore, the electronic connection is considered 
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 an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection.  
 
We also decided that the Plan does not have to pre-approve a backup camera bracket and backup 
camera. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met.  

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 a backup camera bracket and backup 
camera. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
backup camera is a convenience item and not medical in nature. Therefore, the backup camera and backup 
camera bracket are not 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 a backup camera bracket and backup camera have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a backup camera bracket and backup camera. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for SNF care for the enrollee.
You asked the Plan to provide coverage for SNF care. You say that at the time of the appeal, SNF care was
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 provided additional medical records.
The Plan noted that the enrollee was a long-term care custodial resident as of August 4, 2022. The enrollee had
difficulty participating in physical therapy and refused to walk. The enrollee was being trained to use a scooter.
The Plan is correct in this case. 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. The
medical records provided do not show that at the time of the appeal, the enrollee did not require daily skilled
nursing or daily skilled therapy services at an inpatient SNF level of care. At the time of the appeal, the
enrollees' needs were custodial in nature. Medicare rules for coverage of SNF care have not been met.
Therefore, we decided that the Plan does not have to provide coverage for skilled nursing facility (SNF) care
for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code J2001. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code J2001 is bundled into payment 
for code 20611. 
 
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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided on August 18, 
2021. 
 
You asked the Plan to pay for presumptive drug screening. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says there is no evidence that this test 
was requested by the enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 presumptive drug screening have been 
met. Specifically, the physician order does not note that a presumptive drug screening was requested for this 
enrollee. In addition, there is no physician notes or medical records indicating intent to perform presumptive 
testing. Therefore, we decided that the Plan does not have to pay for presumptive drug testing (80307) provided 
on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x3), and core buildups (D2950 x3). 
 
You asked the Plan to pre-approve crowns, and core buildups. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 pre-approve 
crowns (D2740 x3), and core buildups (D2950 x3).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87798. We decided that the Plan does not have to pay 
for procedure codes 87150 and 87641.  
 
You asked the Plan to pay for procedure codes 87150, 87798 and 87641 billed for date of service July 18, 
2022. You say that these services were necessary and are supported in the medical record. The Plan says that 
the payment for these services is included in the payment for other services provided on this date. 
 
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 decided that the Plan has to pay for procedure code 87798.  
 
In this case, we have confirmed that code 87798 is a column II code to column I code 87801; however, code 
87798 was billed with a modifier.  
 
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 code 87798. Our reviewer says that the 91 modifier is 
supported for this code. Our reviewer found that the medical documentation does support the billing of code 
87798 with modifier 91 as the sample was tested for several organisms via amplified probe. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87798 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87798.  
 
We also decided that the Plan does not have to pay for procedure codes 87150 and 87641. 
 
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 procedure codes 87150 and 87641. Our reviewer says that 
these services are not supported in the medical record. Our reviewer found that the medical record does not 
support the use of code 87641 as the documentation specifically states that the sample was not tested for 
staphylococcus aureus. The records also do not support the use of code 87150 as there were no results for the 
sample being cultured. Modifier 91 would also not be supported for these codes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150 and 87641 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87150 and 87641. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on October 26, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you need this for your pain and it should be 
covered. 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 chiropractic visit 
provided on October 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on August 02, 2022, to 
September 27, 2022. 
 
You asked the Plan to pay for psychotherapy 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 psychotherapy visit 
provided on August 02, 2022, to September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and custom fabricated abutment 
(D6057). 
 
You asked the Plan to pre-approve the dental services. You say that your snap on dentures you have are 
ineffective and do not sit right 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 Plan's 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 authorization number 0043195506 and 
appeal A23079698654 when the Plan approved three pontic and two custom fabricated abutments. Therefore, 
we decided that the Plan does not have to pre-approve an additional pontic (D6245) and custom fabricated 
abutment (D6057).