Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 24, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you disagree with the denial and have 
submitted medical records along with all the required documents for processing of payment on this claim. The 
Plan denied your request. The Plan says you are not enrolled in Medicare as a durable medical equipment 
supplier. Therefore, the claim remains denied. 
 
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 diabetic supplies provided on July 
24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 17, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that the claim was denied without submitted 
medical records being adequately examined. You are requesting reconsideration. The Plan denied your request. 
The Plan says you are not enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim 
remains denied. 
 
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 diabetic supplies provided on August 
17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary complete denture (D5110) and 
mandibular complete denture (D5120) provided on August 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your provider told you the dentures would 
be covered under your insurance. You still have money left in your annual allowance and that should be used to 
pay for the dentures. 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 the maxillary complete denture (D5110) and 
mandibular complete denture (D5120) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided on  
July 6, 2023 and July 13, 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 are not payable as they were 
rendered by an ineligible provider.  
 
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. 
 
A 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 acupuncture treatments (97813, 
97814) provided on July 6, 2023 and July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for cone beam computed tomography (CT) capture of the 
jaw (D0367) provided on October 23, 2023. 
 
You asked the Plan to reimburse for cone beam CT capture of the jaw. You say that you already paid the 
provider. You also say you want to know why this was denied before submitting for reimbursement. The Plan 
denied your request. The Plan says this 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 reimburse for 
cone beam computed tomography (CT) capture of the jaw (D0367) provided on October 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7220) provided on August 
28, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider told you surgery was not 
necessary, and no surgery was listed on the description of services. The Plan denied your request. The Plan 
says this service is not a covered benefit under your dental 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 pay for the 
removal of impacted tooth (D7220) provided on August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on February 8, 2023. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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. 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. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on 
February 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 2, 2023, to 
October 3, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Home Health agencies (HHA's) must submit 
home health claims with a type of bill with the 4th digit of 9. 
 
We looked at the file and Medicare rules. The claim was not billed with a valid type of bill. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on October 2, 
2023, to October 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
August 18, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was not 
rendered on the basis of a covered diagnosis.  
 
 
  
 
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 acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatment (97810, 97811) provided on August 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the chemotherapy and the office visit on 
October 2, 2023.  
 
You asked the Plan to waive the cost share for the chemotherapy and the office visit. You say that you believe 
you should have been notified that there was a rise in coinsurance due to a rise in units for the procedure. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for all other Part B drugs. You must pay a $35 copayment per specialist in-person 
or telehealth visit. The provier billed in the amount of $9,000 and the allowed amount is $5,676. For the service 
it's $5,676 x 20% = $1,135.20. The provider billed in the amount of $6 and the allowed amount is $0.69. For 
the service it's $0.69 x 20% = $0.14. For all services it's $1,135.20 + $0.14 + $35 = $1,170.34. Therefore, 
results in the total cost sharing amount of $1,170.34.  
 
The enrollee has been asked to pay a 20% coinsurance for the chemotherapy and a $35 copayment for the 
office visit. This item/service falls within the Medicare Part B prescription drugs and physician/practitioner 
services, including doctors office visits benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost 
share for the chemotherapy and the office visit on October 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 14, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you are requesting reconsideration of the 
claim stating it was denied without submitted medical records being adequately examined. You also say the 
provider submitted proof of delivery along with other supporting documentation. The Plan denied your request. 
The Plan says you are not enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim 
remains denied. 
 
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 diabetic supplies provided on August 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 00904 billed for 
date of service August 21, 2023. 
 
You asked the Plan to pay for 00904. You say that 00904 should be paid as billed because the diagnosis codes 
assigned are correct and valid. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N81.81 has an Excludes1 note in relation to N99.3. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for 00904 have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services described by code 00904 billed for date of service August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pre-approve a crown (D6740) for tooth #11 and a pontic (D6245) for
tooth #10.

You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your
benefit for the requested item or service has already been exhausted. Maximus partially overturned the Plans
denial for code D2740. The Plan requested a reopen and provided additional information. The Plan noted that
in the first request your dentist sent a corrected form correcting the code for tooth #11 to D6740. The records
show you did have available benefits for code D6740 (Tooth 11), as this service has a limit of 4 services per
year. The Plan provided the records to show code D6740 was previously approved for teeth numbers 7, 8, 9
and 10, reaching the contract benefit maximum.

The Plan is correct in this case. 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. The Plan has provided records to show the benefits
requested for code D6740 for tooth #11 and D6245 for tooth #10 had been exhausted prior to the request for
these services. Therefore, we decided that the Plan does not have to pre-approve a crown (D6740) for tooth #11
and a pontic (D6245) for tooth #10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion. 
 
You asked the Plan to pre-approve a sacroiliac joint fusion. The Plan denied your request. The Plan says a 
sacroiliac joint fusion is not medically necessary. 
 
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 a sacroiliac joint fusion. Our reviewer 
says that a sacroiliac joint fusion is not medically necessary. Our physician reviewer found that there is no 
sacroiliac joint instability fracture or lesion. Therefore, a sacroiliac joint fusion is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint fusion.
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 on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
You also say to please review the appeal letter and process the claim. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and 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 a continuous 
glucose monitor (CGM) provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on May 3, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested services are 
covered by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses billed for date of service November 10, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. 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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records do not show that the enrollee was being treated for 
a knee condition or that orthoses was part of the enrollees treatment plan. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthoses billed for date of service November 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938-TC, 95861-TC, 95868-TC, 95927-
TC, and 95940 billed for date of service July 18, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940. You 
say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says these 
codes are included in the facility payment and are 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 these services were provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938-TC, 95861-TC, 
95868-TC, 95927-TC, and 95940. This means there is both a professional and technical component for the CPT 
code(s). In this case, an appropriate modifier to indicate the professional component has not been billed with 
CPT code(s) 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 95938-TC, 95861-TC, 95868-TC, 95927-TC, and 95940 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95938-TC, 
95861-TC, 95868-TC, 95927-TC, and 95940 billed for date of service July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220) provided 
on October 9, 2023. 
 
You asked the Plan to pay for intraoral periapical radiographic images. You say that you were not aware that 
this service was not covered. The Plan denied your request. The Plan says the service at issue 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 intraoral 
periapical radiographic images (D0220) provided on October 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuropathy panel test. 
 
You asked the Plan to pre-approve the requested testing. You say that the enrollee may suffer from an 
autonomic neuropathy. The Plan denied your request. The Plan says the test will not alter the treatment plan.  
 
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 requested testing. Our physician 
reviewer found that the enrollee has a history of longstanding hyperhidrosis. There is no documentation that the 
panel testing is indicated for the enrollee's condition. The records do not document that the panel testing will 
directly impact treatment and/or management of the enrollee's condition. The records do not document signs or 
symptoms for which the testing would generally be considered clinically reasonable and necessary based on 
published peer reviewed medical literature as required.  
 
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 requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a neuropathy panel test.