Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 04, 2023. 
 
You asked the Plan to pay for the wound care services. You say that you are requesting reconsideration for 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 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 wound care services provided on September 04, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on September 26, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you were 
sent for and ultrasound and a CT scan and feels one of the two test was not necessary. 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 $140 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $140 copayment for the computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and 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 copayment for the computed tomography (CT) scan provided on September 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on August 21, 2023. 
 
You asked the Plan to pay for debridement. 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 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 debridement provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 21, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for services provided on February 21, 2023, under code 99223.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did
not apply the correct billing criteria. The Plan noted this claim denied because payment had already been made
under claim 820230600218224. The records show the enrollee was in outpatient observation on February 21,
2023, and February 22, 2023. The appealed claim was billed with a Place of Service code of 21 for Inpatient
Hospital but the referring claim was billed with a Type of Bill 131 code of Outpatient Hospital. Therefore, this
flagged an error for payment.

The Plan is correct in this claim. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, this claim denied because of an error between the Type of Bill code and
the Place of Service code billed.

Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have
to pay for services provided to the enrollee on February 21, 2023, under code 99223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377) and harness (E2313) for the enrollee.

You asked the Plan to pre-approve an electronic connection, expandable controller and harness. You say that
these items are medically necessary. The Plan denied your request. The Plan says that the enrollee's upper limb
function is sufficient to control power options with the switches included with them.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection, expandable controller and harness. Our Medical Director states that the enrollee has right sided
hemiparesis and lower extremity weakness following a gunshot wound to the head. It is documented that the
enrollee is independent with dressing, feeding, grooming/hygiene, and toileting. The enrollee's gait is
shuffling, leaning to the left side, limping with a cane. The documentation supports that the enrollee's left
upper extremity strength is adequate to control the power options using their own switches. The requested
items were not medically reasonable and necessary for the enrollee in this case. Our Medical Director found
that your condition does not meet criteria for coverage of an electronic connection, expandable controller and
harness.

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, expandable controller and harness have not been met.
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable
controller (E2377) and harness (E2313) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) (D0367), gingival 
irrigation (D4921), a retainer crown (D6750) for tooth 12, extraction of erupted tooth (D7210) for tooth13, 18, 
and 31, bone replacement graft for ridge preservation (D7953) for tooth 18, 13, and 31, guided tissue 
regeneration (D4266) for tooth 13, 18 and 31, a porcelain or ceramic pontic (D6245) for tooth 7, 8, 9, 10, 
and13, retainer crown (D6740) for tooth 6, 11 and 14, core buildup (D2950) for tooth 6, 11, and 14, periodontal 
maintenance (D4910), and comprehensive periodontal maintenance (D0180) from September 18, 2023, to 
November 1, 2023. 
 
You asked the Plan to pay for a cone beam computed tomography (CT), gingival irrigation, a retainer crown 
for tooth 12, extraction of erupted tooth for tooth13, 18, and 31, bone replacement graft for ridge preservation 
for tooth 18, 13, and 31, guided tissue regeneration for tooth 13, 18 and 31, a porcelain or ceramic pontic for 
tooth 7, 8, 9, 10, and13, retainer crown for tooth 6, 11 and 14, core buildup for tooth 6, 11, and 14, periodontal 
maintenance, and comprehensive periodontal maintenance. You say that you would like these charges to be 
paid as a medical necessity due to your existing medical conditions. The Plan denied your request. The Plan 
says these services are not covered under your 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 a cone 
beam computed tomography (CT) (D0367), gingival irrigation (D4921), a retainer crown (D6750) for tooth 12, 
extraction of erupted tooth (D7210) for tooth13, 18, and 31, bone replacement graft for ridge preservation 
(D7953) for tooth 18, 13, and 31, guided tissue regeneration (D4266) for tooth 13, 18 and 31, a porcelain or 
ceramic pontic (D6245) for tooth 7, 8, 9, 10, and13, retainer crown (D6740) for tooth 6, 11 and 14, core 
buildup (D2950) for tooth 6, 11, and 14, periodontal maintenance (D4910), and comprehensive periodontal 
maintenance (D0180) from September 18, 2023, to November 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 24, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided the required 
documents and would like the claim processed. The Plan denied your request. The Plan says the documentation 
requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test (0012M) provided June 16, 2023. 
 
You asked the Plan to pay for the CxBladder test. You say that you believe the evidence supporting the use of 
CxBladder Monitor as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CxBladder panel remains unproven at this time. 
 
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 CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for 
the CxBladder test (0012M) provided June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous glucose monitor (cgm) 
supplies provided on September 17, 2023. 
 
You asked the Plan to waive the coinsurance for continuous glucose monitor (cgm) supplies. You say that you 
do not agree with the cost sharing. 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 in and out-of-network Medicare-covered durable medical equipment. 
 
You have been asked to pay 20% coinsurance for continuous glucose monitor (cgm) supplies. This item/service 
falls within the in and out-of-network Medicare-covered durable medical equipment 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 you owe is $51 
($255.01 allowed amount x 20% = $51). Therefore, we decided that the Plan does not have to waive the 
coinsurance for continuous glucose monitor (cgm) supplies provided on September 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
records do not support the need for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  The file shows that a non-standard seat frame (code E2201) was requested. The requested seat frame has a width greater than or equal to 20 inches and less than 24 inches. The records provided do not show that seat frame with these dimensions is required for the enrollee. 
 
The file shows that adjustable angle footplates (code K0040) were requested. The requested footplates are 
covered when provided with power elevating leg rests (code E1012. As a power wheelchair has not been 
requested, this power option cannot be approved.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-
approve wheelchair options and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for lab services (81479) provided on September 23, 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 this claim was not billed with the appropriate code. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan noted
that the correct coding for this service is 0326U. Per Local Coverage Article (LCA) A5726 the provider should
select the correct code. The correct code for this service is 0326U as indicated by the Palmetto MolDX
recommended CPT Codes. The Plan notes they have communicated this error to the provider and corrected
claims have been submitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report with the appropriate code.
In this case, this claim could not be paid as billed due to the submission of an incorrect code, 81479. Based on
this information, we decided that Medicare rules for coverage of these services have not been met. The Plan
has communicated with the provider regarding a corrected claim. Therefore, we decided that the Plan does not
have to pay for lab services (81479) provided to the enrollee on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 0241U. 
 
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 87634 
is a column II code to column I code 0241U. 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 87634 billed for date of service November 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
device (A4239) provided July 28, 2023.  
 
You asked the Plan to pay for the CGM supply allowance. You say that kindly accept our request and reprocess 
our claim. The Plan denied your request. The Plan says the supplies was provided by a provider who is not 
enrolled in Medicare as a durable medical equipment supplier. 
 
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 the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for continuous 
glucose monitor (CGM) device (A4239) provided July 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for sigmoidoscopy and biopsy provided on 
August 24, 2023. 
 
You asked the Plan to waive the copayment for sigmoidoscopy and biopsy. You say that you are asking for a 
reconsideration of the denied claim. 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 outpatient hospital services. 
 
You have been asked to pay a $250 copayment for sigmoidoscopy and biopsy. This item/service falls within the outpatient hospital 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. You have been asked to pay a $250 copayment for outpatient surgery. 
Therefore, we decided that the Plan does not have to waive the copayment for sigmoidoscopy and biopsy 
provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye imaging testing provided on September 11, 2023. 
 
You asked the Plan to pay for eye imaging testing. You say that this was medically necessary and should be 
paid. 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 eye imaging testing provided on September 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 25, 2023 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 25, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) on tooth #12 provided on 
September 29, 2023. 
 
You asked the Plan to pay for the dental service. You say that this is not the same tooth that was repaired in 
2014. You say that the code in 2014 is not the same as now. 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 endodontic therapy (D3320) on tooth #12 was exhausted on date of service June 14, 
2014. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3320) on tooth 
#12 provided on September 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder orthotic provided on June 23, 2023, by an OON provider..

You asked the Plan to pay for a shoulder orthotic. You say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not authorized.

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 a shoulder orthotic provided on June 23, 2023, by an OON provider.