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

 
We decided that the Plan has to pay for a radiologic examination, hand; minimum of 3 views (X-ray) provided 
on September 29, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that Medicare rules for payment of this claim have not 
been met. 
 
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. The Plan only provided the authorization which notes that the member was 
authorized for an inpatient starting on September 29, 2022. We need verification that the member was indeed 
inpatient at the time of service. Therefore, we decided that the Plan has to pay for a radiologic examination, 
hand; minimum of 3 views (X-ray) provided on September 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27130 billed for July 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 27130 was billed with a diagnosis 
code that did not match the -RT laterality modifier. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27130 billed for July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that network participation is not required for Virginia 
providers. The Plan denied your request. The Plan says 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 at issue in this case is not a network provider with the Plan. 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 pay for the office visit. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee was seen for chronic back pain 
with no red flag symptoms. It would have been medically reasonable to delay services until they returned to the 
service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on November 10, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has tried and failed physical 
therapy and occupational therapy with modalities of bracing. It is the medical opinion of the Neurologist that 
without further intervention they will remain without meaningful use of their right upper extremity. The Plan 
denied your request. The Plan says this device is considered experimental and investigational. There is limited 
literature supporting the safety, effectiveness and long term outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this is not a duplicate to the original claim 
filed 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture relining services (D5750, D5751) provided on 
November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for denture relining services (D5750, D5751) provided on November 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a SNF stay provided from September 14, 
2022, to October 5, 2022. 
 
You asked the Plan to waive the coinsurance for a SNF stay. You say that you do not agree with the 
coinsurance responsibility applied. 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 per day for days 1 to 100 for an out-of-network SNF care.  
 
 You have been asked to pay a total coinsurance of $9,135 for a SNF stay. The coinsurance charged is less than 
the standard amount for an out-of-network SNF stay as the out-of-pocket maximum was met with this claim. 
This item/service falls within skilled nursing facility 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 coinsurance for a SNF stay provided from September 14, 2022, to October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network vision diagnostic services and an antireflective
coating provided on January 10, 2022.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says out of network diagnostics and reflective coating are not covered under
the Plan benefit. Maximus partially overturned the coverage for the diagnostic service. The Plan requested a
reopen and stated that out of network diagnostic services are not covered.
The Plan is correct in this case. 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 in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided the
diagnostic service at issue in this appeal. The Plan did not pre-approve the service at issue. In addition, in was
previously agreed that the anti-reflective coating was not a covered benefit. Therefore, we decided that the Plan
does not have to pay for out of network vision diagnostic services and an anti-reflective coating provided on
January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 21, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 March 21, 2022 and July 
27, 2022. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) 
provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the cervical 
spine (72040) provided on December 21, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the cervical spine (72040) 
provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid (V5261) and the conformity 
evaluation (V5020) provided on June 16, 2022 and July 7, 2022. 
 
You asked the Plan to issue reimbursement for this item/service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item/service 
at issue are not payable as they were not rendered by the Plan's select hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids/services only when rendered by the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item/service have not been met. Specifically, the Plans contract provides coverage for hearing 
aids/services only when rendered by the Plans select hearing aid provider. However, the hearing aid/service at 
issue in this case were not rendered by the Plans select hearing aid provider. Therefore, we decided that the 
Plan does not have to issue reimbursement for the hearing aid (V5261) and the conformity evaluation (V5020) 
provided on June 16, 2022 and July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck, lower 
back, and upper back. 
 
You asked the Plan to pre-approve the MRI's. You say that your physician requested the MRI's. The Plan 
denied your request. The Plan says there were no exam results that included a detail of the nervous system. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI's. Our reviewer says that the 
MRI of the neck, lower back, and upper back is not medically necessary. Our physician reviewer found that the 
enrollee has a history of diffuse spine pain without focal tenderness. The enrollee has a history of osteoporosis 
and probable rheumatoid arthritis. During their recent encounters no point tenderness and no focal neurological 
findings. There have been no plain films of the spine done. Plain films are the first exam that is in order in a 
case where there is pain and no neurological deficit or symptom and a history of osteoporosis. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI's have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the neck, lower back, and upper back.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74170 billed for date of service August 24, 
2022. 
 You asked the Plan to pay for procedure code 74170. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 74170 is bundled into payment for code 
74178. 
 
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 74170 
is a column II code to column I code 74178. 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 74170 billed for date of service August 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services billed to the enrollee for March 15, 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 for
insufficient information in the case file. The Plan requested a reopen and provided additional explanation. The
Plan noted that this claim denied because the service was inappropriately billed with an incorrect Type of Bill
Code of 323 or Home Health Agency/Inpatient/Interim-Continuing Claims. The Plan determined this Home
Health Service should be billed with TOB 322, 329, or 327.
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 was submitted with an inappropriate TOB code. Therefore, we
decided that the Plan does not have to pay for home health services billed to the enrollee for March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle  (D4381), comprehensive oral evaluation - new or established patient (D0150), gingival 
irrigation  per quadrant (D4921), and intraoral - complete series of radiographic images (D0210) provided on 
October 10, 2022, and November 2, 2022. 
 
 
 
 You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the comprehensive oral evaluation (D-0150) has already been exhausted. Localized delivery of antimicrobial 
agents via a controlled release vehicle  (D4381), gingival irrigation  per quadrant (D4921), and intraoral - 
complete series of radiographic images (D0210) are not covered by the Plans dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation (D-0150) was exhausted on date of service July 13, 
2022.  Localized delivery of antimicrobial agents via a controlled release vehicle  (D4381), gingival irrigation  
per quadrant (D4921), and intraoral - complete series of radiographic images (D0210) are not covered by the 
Plans dental benefits  Therefore, we decided that the Plan does not have to pay for localized delivery of 
antimicrobial agents via a controlled release vehicle  (D4381), comprehensive oral evaluation - new or 
established patient (D0150), gingival irrigation  per quadrant (D4921), and intraoral - complete series of 
radiographic images (D0210) provided on October 10, 2022, and November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement and osseous contouring of a peri-implant defect 
or defects surrounding a single implant (D6102), bone graft for repair of peri-implant defect (D6103), 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous moderate 
sedation/analgesia  each subsequent 15 minute increment (D9243) provided on July 21, 2022. 
 
You asked the Plan to pay for codes D6102, D6103, D9239 and D9243. You say that the provider cannot be 
out-of-network as she lives in the same city. You also say that you would like the Plan to reverse the decision 
and pay the bill. The Plan denied your request. The Plan says these services are not covered under the benefit 
package. 
 
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 
debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant (D6102), 
bone graft for repair of peri-implant defect (D6103), intravenous moderate (conscious) sedation/analgesia- first 
15 minutes (D9239), and intravenous moderate sedation/analgesia  each subsequent 15 minute increment 
(D9243) provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 07, 2022. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on November 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided by an out-of-
network provider on October 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider submitted the correct code for 
payment. The Plan denied your request. The Plan says the dental service was received from an out-of-network 
provider and is not covered by your supplemental 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. 
 
  The record shows you received the requested dental service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for a periodic oral evaluation (D0120) provided by an out-of-network provider on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a pain in your jaw and called your old 
dentist. You also say that you have not used your benefits in a very long time and expect the Plan to cover this 
emergency service. 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 July 6, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on November 17, 2022.