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

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 27, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that you have submitted the Medicare 
enrollment letter.  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 an emergency department visit provided on August 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D1110, D0330, and D0120) on June 27, 
2023. 
 
You asked the Plan to pay for the dental services (D1110, D0330, and D0120). You say that you would like to 
request reconsideration for payment. 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 the dental services (D1110, D0330, and D0120) on June 27, 2023.
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 May 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your father 
has dementia and upon arrival of the emergency personnel his vitals were back to normal and he was feeling 
better. You also say that he did not want to go to the emergency room and to save costs for him and the plan 
you let him make his own decision not to go 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 May 4, 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 May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture provided on July 20, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a covered benefit, and the 
Plan has reimbursement you before. The Plan denied your request. The Plan says acupuncture is only covered 
to treat CLBP. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services at issue were not used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 21, 2023, billed with 
procedure code 99223-57. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the documentation provided did not include an evaluation and management report for 
the date of service in question.. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on June 21, 2023, billed with procedure code 99223-57.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided November 10, 2022, 
billed with codes 87798 x13, 87653, 87640, 87481, and 87186 x12.  
 
You asked the Plan to pay for the laboratory service. You say that please reconsider this claim for payment. 
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 a panel that was not billed with a single panel code as 
required. Also, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. The urinalysis and urine culture have been approved. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the Urine PCR panel testing provided November 10, 2022, billed with codes 
87798 x13, 87653, 87640, 87481, and 87186 x12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you cannot turn your neck without 
extreme pain. You say that you visited a chiropractor who has made the pain worse, and the acupuncture 
service is the only thing left before surgery. You say that you really do not want to have the surgery, but the 
pain is affecting your quality of life. The Plan denied your request. The Plan says that acupuncture is only 
covered for chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you are having pain in your neck, and acupuncture is 
only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture provided on June 13, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a covered benefit, and the 
Plan has reimbursement you before. The Plan denied your request. The Plan says acupuncture is only covered 
to treat CLBP. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, services at issue were not used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on July 28, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says that the 
requested service is non-coverable. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide the continuous glucose monitor (CGM).  
You asked the Plan to provide the CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to provide the CGM. Our physician reviewer found the 
record indicates that the enrollee has diabetes. The record provided does not include primary source 
documentation and does not indicate that the enrollee is being treated with insulin or has problematic 
hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to provide the continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve the non-emergent transportation trips. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you only have one remaining trip before 
exceeding your benefit limit for the period. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional non-emergent transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 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 treat within 
insulin or have a history of problematic hypoglycemia. 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 
pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx test (0339U) provided to the enrollee on
January 10, 2023.

You asked the Plan to pay for the SelectMDx test. You say that since specimens for your testing are obtained
during procedures not performed at your office, you are unable to obtain prior authorization and proactively
inform patients of their individual coverage benefits for our services. The Plan denied your request. The Plan
says that under Medicare rules the request for SelectMDx is not a covered benefit because this is not a test
which has met the coverage criteria. Maximus overturned the Plan's denial based on medical necessity. The
Plan requested a reopening and stated that the testing was not denied for medical necessity but because it was
not covered at the time of service. The Plan is correct in this case. The rules say that that only the Progensa
PCA3 and ConfirmMDx tests have met Medicare coverage criteria. We looked at the file and Medicare rules.
The testing at issue is SelectMDx. This test was not covered by the Medicare criteria at the time the service was
received. Based on this information, we decided that Medicare rules for coverage of the SelectMDx test have
not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx test (0339U)
provided to the enrollee on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112), ultrasound therapy 
(97035), and the electric stimulation therapy (97014) provided on June 21, 2023. 
 
You asked the Plan to pay 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 the services at issue are not a covered benefit 
by Medicare or the Plan.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the neuromuscular reeducation (97112), ultrasound therapy (97035), and 
the electric stimulation therapy (97014) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D4910) on August 29, 2023. 
 
You asked the Plan to pay for the dental service (D4910). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service (D4910) is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D4910) on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service rendered by a dentist or 
physician other than requesting dentist or physician (D9310) and the cone beam computed tomography (CT) 
capture and interpretation with limited field of view-less than one whole jaw (D0364) provided on July 27, 
2023. 
 
You asked the Plan to pay 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 the services provided in this case are not 
covered under the supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service rendered by a dentist or physician other than requesting dentist or physician (D9310) and the 
cone beam computed tomography (CT) capture and interpretation with limited field of view-less than one 
whole jaw (D0364) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the additional 6 trips are needed for the 
enrollee's appointments. The Plan denied your request. The Plan says the record shows the enrollee has used all 
12 allowed one-way trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 6 
additional routine transportation trips for the enrollees appointments. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with codes 87532, 87496, 87798, 87486, 87581, 87640, and 87541 for date of service May 10, 2023.

You asked the Plan to pay for the laboratory services billed with codes 87532, 87496, 87798, 87486, 87581, 87640, and 87541. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.

We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code with one unit of service should be used. Based on this information, we decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87532, 87496, 87798, 87486, 87581, 87640, and 87541 for date of service May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dentures. The 
Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
dentures are 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 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 a 
complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel billed with 
codes 87640, 87481, 87798, 87653, and 87186 for January 27, 2022. 
 
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 a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 the urine polymerase chain reaction (PCR) 
panel billed with codes 87640, 87481, 87798, 87653, and 87186 for January 27, 2022.