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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you started 
turning blue so you called 911. You also say that you were treated by the ambulance personnel and opted out of 
being transported to the hospital. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 8, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal surgery (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that bone marrow aspirate is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says bone marrow aspirate is 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental when used as bone graft in spine surgery.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal surgery (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on August 2, 2023. 
 
You asked the Plan to pay for the consultation. You say that you would like to have the service covered as you 
are in extreme pain and need the extraction of the tooth that was examined. The Plan denied your request. The 
Plan says this service is not covered by the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on August 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81351 and 81406 billed for April 11, 2023. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 codes 81351 and 81406 billed for 
April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified periodontal procedure, by report (D4999) 
provided on May 24, 2023, and May 25, 2023. 
 
You asked the Plan to pay for the unspecified periodontal procedure, by report. You say that you need 
additional dental work and you have no funds for the proposed services. The Plan denied your request. The 
Plan says this service is not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested  service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
periodontal procedure, by report (D4999) provided on May 24, 2023, and May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 billed for June 1, 2023. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 96401is not intended to be reported by the 
individual physician or other qualified health care professional in the facility setting. 
 
We looked at the file and Medicare rules. The file shows that code 96401 was billed by a physician in the 
facility setting. Therefore, we decided that the Plan does not have to pay for procedure code 96401 billed for 
June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 2, 2023, by an out-of-network (OON) provider. 

You asked the Plan to pay for the office visit. 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.

We looked at 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 the office visit provided on August 2, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty (22514). 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 vertebroplasty/kyphoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documented trial of bracing for fracture care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty/kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertebroplasty/kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from May 11, 2023, to June 21, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you cannot afford to keep 
going to see your chiropractic because you are on a fixed income. You say these visits are so you can walk and 
that is why you need the reimbursement. The Plan denied your request. The Plan says the services are not 
covered because the provider does not accept insurance. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
chiropractic services provided by from May 11, 2023, to June 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Neuropsychological Testing (96116 x 1, 96121 x 2, 
96133 x 1, 96137 x 4, 96138 x1 and 96139 x 11, or a total of 12 hours). 
 
You asked the Plan to pre-approve the Neuropsychological Testing. You say that the service is medically 
necessary. The Plan denied your request. The Plan says there is no explanation of why they are requesting more 
than 8 hours, which is the industry standard for testing. 
 
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 Neuropsychological Testing. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found extensive testing is not required for evaluation of the enrollee's diagnosis. 
 
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 Neuropsychological Testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Neuropsychological Testing (96116 x 1, 96121 x 2, 96133 x 1, 96137 
x 4, 96138 x1 and 96139 x 11, or a total of 12 hours).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you have been getting a new wheelchair yearly. You also say that you had a stage 4 bed sore, it just got it 
healed and you do not need to go through that again. The Plan denied your request. The Plan says that although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found you are non-ambulatory and require a power 
wheelchair for mobility and performing daily activities. You cannot perform pressure relief independently due 
to upper extremity weakness and require a power wheelchair with power tilt and recline for adequate pressure 
relief and positioning. There is a history of skin breakdown. Our reviewer found that power elevating leg rests 
are required for positioning of the lower extremities and lower extremity spasticity. The complexity of your 
seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our physician 
reviewer also found that the expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options via a joystick. These components are 
required to operate 3 or more power options on a group 3 power wheelchair. 
 
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, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).   
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on June 
10, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you had a low sugar 
attack and received treatment in home. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 10, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 out-of-network provider on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on June 12, 2023. 
 
You asked the Plan to pay for the office visit. You say that you visited the chiropractor for severe back pain. 
You say that after the visit your pain decreased significantly. The Plan denied your request. The Plan says that 
the only covered chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on May 5, 
2023, by an OON provider.  
 
You asked the Plan to pay for re-cement or re-bond crown by an OON provider. You say that this was 
medically necessary. The Plan denied your request. The Plan says OON providers are 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 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 re-cement or re-bond crown (D2920) provided on 
May 5, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional funds for hearing aid coverage.

You asked the Plan to provide additional hearing aid coverage. The Plan denied your request. The Plan says the
requested hearing aids exceed the $2600 benefit and that you are responsible for any amount over the $2600.
Maximus overturned the Plans denial because a Plan contract was not included in the case file that explained
the hearing aid benefit. The Plan requested a reopen and submitted the required contract information.

The Plan is correct in this case. 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 Plan's coverage rules apply in
this case. The Plan pays for hearing aids up to $2600. Anything over $2600 is your financial responsibility.
Medicare does not require plans to make exceptions to supplemental benefit. Therefore, we decided that the
Plan does not have to provide coverage for additional funds for hearing aid coverage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service March 21, 
2023. 
 You asked the Plan to pay for procedure code G0416. You say that a corrected claim was submitted. The Plan 
denied your request. The Plan says this code is included in the facility payment and 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 the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code G0416. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with code G0416. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0416 billed for date of service March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on May 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe the plan should pay more. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an out-of-
network provider on May 23, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 4, 2023. 
 You asked the Plan to pay for the ambulance services. You say that you don't understand why the payment was 
recouped and ask that the claim be reprocessed. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on February 4, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF level of care to regain maximum 
function. The Plan denied your request. The Plan says a SNF admission is not medically necessary.   
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.