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

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) provided on June 
30, 2023, to July 14, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT). You say that the services should be 
covered. 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 chiropractic 
manipulative treatment (CMT) provided on June 30, 2023, to July 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sexually transmitted disease (STD) screening testing 
(87481 and 81513) provided June 22, 2022. 
 
You asked the Plan to pay for the STD screening. You say that attached are medical records to support this date 
of service. The Plan denied your request. The Plan says screening testing for sexually transmitted disease is not 
listed as a covered service under Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the STD screening, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the sexually transmitted disease (STD) screening testing (87481 and 81513) provided June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for eye surgery provided on May 03, 2023. 
 
You asked the Plan to waive the coinsurance for eye surgery. You say that you say that you are vein charged an 
out-of-network copay for eye surgery. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay 30% coinsurance for eye surgery. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 $735.58 ($2,451.93 allowed amount x 30% = $735.58). Therefore, we decided that the Plan 
does not have to waive the coinsurance for eye surgery provided on May 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA 1/2 panel (81433) provided on June 8, 
2023. 
 
You asked the Plan to pay for the Invitae BRCA 1/2 panel. You say that this test was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the Invitae BRCA 1/2 panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Invitae BRCA 1/2 panel (81433) provided on June 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on June 23, 
2023. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you say that you were told by 
the provider staff that this transport would be covered and gave the impression that it would not cost you 
anything. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for ambulance service. This item/service falls within the 
ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for ambulance service 
provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a prefabricated post and core in addition to crowns (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the request is medically necessary. Our physician reviewer found that there is a dark area at the end of the 
root of tooth number 9 indicating that the tooth is no longer vital. When there is not enough natural tooth 
structure to retain a crown, a buildup is placed along with a post. There were no x-rays included of tooth 
number 9 with a completed root canal treatment. If a root canal is done on tooth number 9, a post, buildup, and 
a crown would be needed to restore the tooth to its full function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a prefabricated post and core in addition to crowns (D2954).  
 
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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 81226, 81227, 81240, 
81241, 81328, and 81479. We decided that the Plan does not have to pay for the services described by 
procedure codes 81225, 81231, 81232, 81306, and 81335.  
 
You asked the Plan to pay for the lab testing billed for date of service May 8, 2023. You say that the treatment 
sought was medically necessary. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for the services described by procedure codes 81226, 81227, 81240, 
81241, 81328, and 81479.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 81226, 81227, 81240, 81241, 
81328, and 81479 billed for date of service May 8, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 81225, 
81231, 81232, 81306, and 81335. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a combined cardio and pharmacogenomics panel test was provided. We looked at the file 
and Medicare rules. This NGS panel was not billed with a single code as required. 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 the services described by procedure codes 81225, 81231, 81232, 81306, and 81335 billed for 
date of service May 8, 2023. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provide December 1, 2022, 
billed with codes 87798 x12, 87511-59, 87481-59, G0452-26. 
 
You asked the Plan to pay for the laboratory testing. You say that you believe that the denial of this claim 
based on the grounds of medical necessity is incorrect. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel testing 
provide December 1, 2022, billed with codes 87798 x12, 87511-59, 87481-59, G0452-26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the psychotherapy services, 45 minutes 
(90834), group psychotherapy services (90853), psychotherapy services, 60 minutes (90837), psychotherapy 
services, 30 minutes (90832), psychiatric diagnostic evaluations (90791), inpatient or observation consultations 
(99255), subsequent hospital inpatient or observation care services, per day (99231, 99232, 99233), and the 
discharge day management (99239) provided from May 20, 2022, through May 30, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services 
at issue are not payable as the providers in this case have opted out of the Medicare program.  
 
 
  
 
 
 
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 providers who 
have opted out of the Medicare program. Therefore, we decided that the Plan does not have to issue 
reimbursement for the psychotherapy services, 45 minutes (90834), group psychotherapy services (90853), 
psychotherapy services, 60 minutes (90837), psychotherapy services, 30 minutes (90832), psychiatric 
diagnostic evaluations (90791), inpatient or observation consultations (99255), subsequent hospital inpatient or 
observation care services, per day (99231, 99232, 99233), and the discharge day management (99239) provided 
from May 20, 2022, through May 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on August 23, 
2023. 
 
You asked the Plan to waive the copayment for a nuclear stress test. You say that you were told that this 
service would be covered. 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 $200 
copayment for each advanced imaging service, including nuclear medicine, and stress tests. 
 
You have been asked to pay a $200 copayment for a nuclear stress test. This item/service falls within the each 
advanced imaging service, including nuclear medicine, and stress tests 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 a nuclear stress test provided on August 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram provided on July 17, 2023. 
 
You asked the Plan to pay for an echocardiogram. 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 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 echocardiogram 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 05, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that you are participating with the plan. 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 office visit provided 
on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 19, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that authorization is not required. 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 office visit provided 
on June 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network 
esophagogastroduodenoscopy (EGD) provided on July 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network esophagogastroduodenoscopy (EGD). You say 
that you were told there would not be a copayment for this service. 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, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for an in-network esophagogastroduodenoscopy (EGD). This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 an in-
network esophagogastroduodenoscopy (EGD) provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).

You asked the Plan to provide coverage for a continuous glucose monitor (CGM). The Plan denied your
request. The Plan says the required coverage criteria are not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at
least three daily injections.

We looked at the file and Medicare rules. Medicare rules for coverage of a continuous glucose monitor (CGM)
have not been met. The medical records do not show the enrollee uses three injections per day. Therefore, we
decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on June 30, 2023, to July 03, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you cannot 
afford these copayments. 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 $275 
copayment for inpatient hospital care. 
 
You have been asked to pay a $275 copayment for an in-network acute inpatient stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay a total of $825 for the inpatient hospital stay ($275 
copayment x 3 days = $825). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided on 
June 30, 2023, to July 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each cystourethroscopy procedure 
provided on April 24, 2023, to July 24, 2023. 
 
You asked the Plan to reduce the copayment for each cystourethroscopy procedure. You say that you disagree 
with the cost share increase. 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 $425 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $425 copayment for each cystourethroscopy procedure. This item/service falls within the outpatient surgery, including services provided at ambulatory surgical centers 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. However, since the 
allowed amount is less than the standard copayment, you only owe $307.90 for each procedure. The total 
amount you owe is $615.80 ($307.90 copayment x 2 procedures = $615.80). Therefore, we decided that the 
Plan does not have to reduce the copayment for each cystourethroscopy procedure provided on April 24, 2023, 
to July 24, 2023.