Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 21, 2023, to May 
20, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 21, 2023. The NOA was not received by the Plan until October 24, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 21, 2023, to May 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography and screening digital breast 
tomosynthesis provided on August 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the screening mammography and screening digital breast tomosynthesis. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services provided are 
not a covered benefit. 
 
 
 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 screening mammography and screening digital 
breast tomosynthesis provided on August 23, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would like a CGM. The Plan denied your request. 
The Plan says the medical criteria needed for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 
You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says according to the 
provided medical records, the drug is being pharmacy dispensed, either directly to the enrollee or shipped to the 
prescriber's office. The Plan also says that this request does not meet the definition of the 'Incident To' 
requirements, as it is not being furnished by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
 
 
 
 
 
 
 In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Epogen (J0885).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 laboratory services 
provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert. 
 
You asked the Plan to pre-approve a Life Alert. You say that you are a senior, lives alone, and have chronic 
blood pressure. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say telephone alert systems are noncovered. 
 
The item at issue is specifically not covered. Therefore, we decided that the Plan does not have to pre-approve 
a Life Alert.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve these services. You say that the enrollee's diagnosis is not specifically listed 
under the enrollee's policy. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99213-25 rendered on January 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the health plan denied coverage for 
the CPT code 99213-25 for dos 1/10/22, stating the available medical records do not support the service billed 
as a significant and separately identifiable evaluation and management service from CPT 97597. The provided 
records do clarify and support that CPT 99213 was a significant and separately identifiable evaluation and 
management service from CPT 97957. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99213-25 rendered on January 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you can only take a few steps before you have 
to rest. You say that your feet get tired and painful or sometimes numb and unable to move. You also say that 
you need a foldable scooter to get around and use to go to the store and appointments. The Plan denied your 
request. The Plan says the notes do not show a reason for which you would not be able to use a manual 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on August 9, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 telehealth services provided on August 9, 
2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sinemet 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sinemet   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951), a guided tissue 
regeneration (D4266), and a second stage implant surgery (D6011). 
 
You asked the Plan to pre-approve D7951, D4266 and D6011. You say that you would like the Plan to approve 
this dental work. The Plan denied your request. The Plan says the requested dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve sinus 
augmentation (D7951), a guided tissue regeneration (D4266), and a second stage implant surgery (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary and mandibular denture (D5213 and 
D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you have lost weight and your old dentures 
no longer fit. 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 June 24, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary and mandibular denture (D5213 and 
D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tizanidine. 
 
You asked the Plan to pre-approve Tizanidine. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tizanidine.  Benefits for Tizanidine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a limited oral 
evaluation-problem focused (D0140) provided on February 9, 2023 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration and have 
enclosed billing statements for review. 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 a panoramic radiographic image (D0330) and a limited oral evaluation-problem focused (D0140) 
provided on February 9, 2023 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for any of these services.

You asked the Plan to waive or reduce this cost share. You say that you should not be responsible for the cost
of these services. 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 contract language.

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 a cost share for each
services provided. This includes Medicare Part B drugs and specialist office visit.

Review of your contract shows you have been asked to pay the correct amount for each drug and service 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 or reduce the cost share
charged for the betamethasone acetate injections provided from October 1, 2020, to September 16, 2022,
dexamethasone sodium injection provided on August 9, 2022, hyaluronan injections provided from August 23,
2022, to September 13, 2022, and the specialist office visits provided from October 27, 2020, to September 16,
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on August 07, 2023. 
 
You asked the Plan to pay for an outpatient surgery. You say that you are requesting reconsideration for 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 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 an outpatient surgery 
provided on August 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) on the 
lower left quadrant provided on July 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you never received a deep cleaning, and you are 
entitled to the benefit. 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 the Plan paid for the periodontal scaling and root planing (D4342) on the lower left quadrant on April 
27, 2022; therefore, your benefit for the requested item or service was exhausted on the date of service of April 
27, 2022. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing 
(D4341) on the lower left quadrant provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on September 15, 2023. 
 You asked the Plan to pay for an eye refraction (92015). You say that you had an infection in your right eye. 
You also say this provider set up a follow up appointment where he found glaucoma in your right eye. The Plan 
denied your request. The Plan says refractive services are only covered if they are part of a routine eye 
examination. 
 
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 the eye refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered when part of 
a routine eye examination. The record shows this was not a routine eye examination. This was a medical or 
diagnostic eye examination. Based on this information, we decided that the Plan's rules for coverage of an eye 
refraction (92015) have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - two 
radiographic images (D0272), panoramic radiographic image (D0330), intraoral - periapical first radiographic 
image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided on February 
14, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 periodic 
oral evaluation (D0120), bitewings - two radiographic images (D0272), panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional 
radiographic image (D0230) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring (CGM) system (A9276) 
provided on September 1, 2023. 
 
You asked the Plan to pay for the CGM system. You say that you believe the CGM should be covered under 
your benefits. The Plan denied your request. The Plan says the claim processed correctly according to the 
contract. 
 
The Plan must follow Medicare rules. Medicare rules say that all CGM devices billed as E2103 must have 
received coding verification review by the Pricing, Data Analysis and Coding (PDAC) contractor and be listed 
on the Product Classification List (PCL) for HCPCS code E2103. 
 We looked at the file and Medicare rules. The CGM, code A9276 is non-covered. Based on this information, 
we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the 
Plan does not have to pay for the continuous glucose monitoring (CGM) system (A9276) provided on 
September 1, 2023.