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

 
We decided that the Plan does not have to pay for a medical eye examination (92004), a computerized scan 
(92134), and fluorescein angiography (92235) provided on July 27, 2023, by an out-of-network provider.  
You asked the Plan to pay for the vision services. You say that you thought this provider was in-network. The 
Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
a medical eye examination (92004), a computerized scan (92134), and fluorescein angiography (92235) 
provided on July 27, 2023, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29125 billed for date of service September 
13, 2023.  
 
You asked the Plan to pay for procedure code 29125. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29125 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29125 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29125 billed for date of service September 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant. 
 
You asked the Plan to pre-approve the implant. The Plan denied your request. The Plan says a spinal cord 
stimulator implant is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the implant. Our reviewer says that a 
spinal cord stimulator implant is not medically necessary. Our physician reviewer found that the enrollee has 
not had prior spine surgery or a recent surgical consultation. Also, the enrollee has not had a thoracic magnetic 
resonance imaging (MRI). Therefore, the request is not 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 the implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator implant.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continuation is medically necessary for you. The 
Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of continued 
admission in skilled nursing facility does not meet the requirements for approval.  
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service September 
12, 2023. 
 
You asked the Plan to pay for procedure code 96040. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 96040 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 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and injection services provided on July 27, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit and injection services. You say that you were unaware that the 
provider was not in network. The Plan denied your request. The Plan says there was no authorization for the 
services. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 office visit and injection services provided on July 27, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce anesthesia services provided on March 23, 2023.

You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this cost share is
correct. The Plan denied your request. The Plan says this cost sharing was charged correctly. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
calculation. The 20% coinsurance should be on the "allowed" amount and not the "allowed less sequestration"
amount.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 20% coinsurance for
outpatient hospital services. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and the prefabricated 
post and core in addition to crown (D2954) provided on September 20, 2023. 
 
You asked the Plan to pay for the intraoral periapical x-ray (D0220) and the prefabricated post and core in 
addition to crown (D2954). You say that you want to be reimbursed for the services rendered. The Plan denied 
your request. The Plan says your benefit for the periapical x-ray (D0220) has already been exhausted and the 
prefabricated post and core in addition to crown (D2954) is not a covered benefit. 
 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 periapical x-rays was exhausted on date of service September 20, 2023, with the 
additional periapical x-ray. The prefabricated post and core in addition to crown (D2954) is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral periapical 
x-ray (D0220) and the prefabricated post and core in addition to crown (D2954) provided on September 20, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport provided on October 
26, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the enrollee was no longer 
enlisted in hospice on October 26, 2023. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 23, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the non-emergent 
ambulance transport provided on October 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on October 9, 2023. 
 
You asked the Plan to pay for an occlusal guard. You say that you thought this item would be covered. The 
Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 
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 an 
occlusal guard (D9944) provided on October 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit and the eye exam provided on June 26, 2023. 
 
You asked the Plan to pay for the clinic visit and the eye exam. You say that you are requesting reconsideration 
of the denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 clinic visit and the eye exam provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on September 06, 
2023, to September 07, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you want to appeal the amount 
being charged. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injections. 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. The total amount you owe is $832.40, which is 20% coinsurance of the allowed amount 
for each item. Therefore, we decided that the Plan does not have to waive the coinsurance for the injections 
provided on September 06, 2023, to September 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 1, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
you have sent all the appropriate documents. The Plan denied your request. The Plan says that you are not 
enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service October 2, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service October 2, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Dexcom G7 sensors. 
 
You asked the Plan to pre-approve the Dexcom G7 sensors. You say that the device is medically necessary to 
monitor the enrollees glucose levels due to dexterity. You also say that the enrollee is unable to physically use 
the glucometer. The Plan denied your request. The Plan says that the enrollee does not meet the rules for CGM 
coverage. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 Dexcom G7 sensor. Our reviewer 
says that this item is medically necessary. Our physician reviewer found the office notes say that the enrollee is 
unable to use a glucometer due to dexterity issues. The use of Trulicity does not necessarily indicate that the 
enrollee's dexterity is sufficient to use a glucometer since this is one of the easier injection devices to use and it 
only involves pushing a button. Since the enrollee's A1C is high and the CGM will likely help them understand 
the impact of different foods on blood glucose sugar levels, the use of the CGM for a month (2 to 3 sensors) is 
reasonable in this case. 
 
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 Dexcom G7 sensor have been met. Therefore, we decided that the Plan has 
to pre-approve the Dexcom G7 sensors.  
 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 procedure code(s) 95938-TC and 95940 billed for date of 
service May 4, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938-TC and 95940. You say that the claim is billed 
correctly and should be paid. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938-TC and 95940. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95938-TC 
and 95940. Based on this information, we decided that Medicare rules for coverage of procedure codes 95938-
TC and 95940 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code(s) 95938-TC and 95940 billed for date of service May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 2, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you needed the eye refraction done as a follow 
up treatment from cataract surgery. The Plan denied your request. The Plan says the benefit for this refraction 
has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per calendar year. 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received an eye refraction (92015) on 
February 23, 2023, and this benefit had been exhausted. Based on this information, we decided that the Plan's 
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the eye refraction (92015) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on August 28, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 dental services provided by an OON provider on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement or rebond of a crown (D2920) provided on 
October 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 10, 2023. 
Therefore, we decided that the Plan does not have to pay for the recement or rebond of a crown (D2920) 
provided on October 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the steroid injection provided on September 
21, 2023. 
 
You asked the Plan to waive the copayment for the steroid injection. You say that the cost share is wrong. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for the steroid injection. This item/service falls within the 
outpatient surgery 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 steroid injection 
provided on September 21, 2023.