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

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on July 16, 2023. 
 
You asked the Plan to pay for a portable chest x-ray. You say that this service was medically necessary. 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 a portable chest x-ray 
provided on July 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the denied dental services are a legitimate 
expense under your dental plan. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) on August 22, 2023, which was processed prior to 
the claim for August 17, 2023; therefore, your benefit for the requested item or service was exhausted on the 
date of service of August 22, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on September 
15, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that this is supported in the records. 
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 provided on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the 
pulp vitality test (D0460) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation provided has already been exhausted. Additionally, the pulp vitality test provided is not a covered 
benefit 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation provided was exhausted on date of service June 20, 2023.  
Specifically, one limited oral evaluation is covered every twelve months. You previously received this service 
on June 20, 2023, less than twelve months prior, which was paid for by the plan. Therefore, you have 
exhausted the allowable benefit for this service. Additionally, the pulp vitality test provided in this case is not a 
covered benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-
problem focused (D0140) and the pulp vitality test (D0460) provided on August 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 provided from July 29, 
2023, to July 30, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99233. You say that the medical records support the 
billing of procedure code 99223 provided on July 29, 2023, and procedure code 99233 provided on July 30, 
2023.  The Plan denied your request. The Plan says the medical records do not support the billing of procedure 
code 99223 provided on July 29, 2023, and procedure code 99233 provided on July 30, 2023.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. The definition of code 99233 is Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 99223 and 99233. Our reviewer says that 
the medical records do not support the billing of procedure code 99223 provided on July 29, 2023, and 
procedure code 99233 provided on July 30, 2023.  Our reviewer found the medical records support a medically 
appropriate examination, but not an appropriate history or high level of medical decision making to justify 
99223 on July 29, 2023. 
 
Also, the medical records support a medically appropriate examination, but not an appropriate history or high 
level of medical decision making to justify 99233 on July 30, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99233 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99233 provided from July 29, 2023, to July 
30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and debridement services 
provided on October 11, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and debridement services. You say that these 
services were medically necessary. 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 subsequent nursing 
facility care, and debridement services provided on October 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), radiographic or 
surgical implant index, by report (D6190), surgical placement of an implant body: endosteal implant (D6010), 
and the surgical removal of an implant body (D6100) provided from January 26, 2022, through September 21, 
2022. 
 
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 covered by 
Medicare or the Plan.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth.   
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does 
not have to pay for the panoramic radiographic image (D0330), radiographic or surgical implant index, by 
report (D6190), surgical placement of an implant body: endosteal implant (D6010), and the surgical removal of 
an implant body (D6100) provided from January 26, 2022, through September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus xT genetic testing coded as 81455 provided to the
enrollee on November 7, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The Plan notes
that the Maximus reviewer did not consider that the submitted medical records state that this enrollee's cancer
was stage I. The records do not support evidence of this enrollee's cancer being either advanced or metastatic.
There is also documentation that the enrollee was not going to require adjuvant treatment.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for this testing. The medical records provided do not demonstrate that the Medicare rules for coverage of this
testing were met. Therefore, we decided that the Plan does not have to pay for Tempus xT genetic testing coded
as 81455 provided to the enrollee on November 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on September 11, 2023. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial payment. The Plan denied your request. The Plan says there is no evidence of a NOA being 
submitted. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on November 7, 2023. 
  
You asked the Plan to pay for the dental services. You say that you were not aware the provider was no longer 
in-network, and you would like the dental services covered. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the intraoral radiographic images 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 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 the 
intraoral radiographic images (D0220 and D0230) provided on November 7, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus xF genetic testing (81455) provided to the enrollee
on January 4, 2022.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says this testing is not FDA approved. Maximus overturned the Plans denial. The Plan
requested a reopen and noted that Maximus did not apply the correct criteria as this test does not have FDA
approval for the enrollee's condition.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires this testing to be FDA
approved. This testing does not have FDA approval or clearance, and an FDA-approved or FDA-cleared
indication for use in this enrollee's condition. Medicare coverage criteria are not met. Therefore, we decided the
Plan does not have to pay for the Tempus xF genetic testing (81455) provided to the enrollee on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator . You say that your oxygen drops down 80% 
while walking. You say that you have been using your sisters portable oxygen concentrator which has recently 
broke. The Plan denied your request. The Plan says that  a portable oxygen concentrator is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
  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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is medically necessary. Our physician reviewer found that 
you have pulmonary hypertension with severe hypoxemia requiring elevated levels of liter flow of oxygen 
delivery. Also, you would benefit and require a portable oxygen concentrator for delivery of oxygen therapy. 
Therefore, you meet the best practice guidelines for a portable oxygen. 
 
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 portable oxygen concentrator have been met.  Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for apixaban provided on June 24, 2023. 
 
You asked the Plan to pay for the medication. You say that you disagree with the denial of payment. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for apixaban provided on June 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on July 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the provider is in network 
with the Plan. The Plan denied your request. The Plan says the chiropractic manipulative treatment is available 
in network. 
 
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 the chiropractic manipulative treatment provided 
on July 1, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reimbursement for transport services received on March 24, 
2023, to July 3, 2023. 
 
You asked the Plan to pay for reimbursement for transport services. You say that the services are a covered 
benefit. The Plan denied your request. The Plan says you did not use an approved vendor for the services. 
 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 routine transportation when services must be received by an approved vendor.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for reimbursement for transport services received on March 24, 2023, to July 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (99213) and fundus photography 
(92250) provided on August 16, 2023.  
You asked the Plan to pay for a medical eye examination and fundus photography. You say that you thought 
the services would be covered. The Plan denied your request. The Plan says these services are not covered 
under the routine vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of a medical eye examination and fundus photography have not been met. Therefore, we decided that 
the Plan does not have to pay for a medical eye examination (99213) and fundus photography (92250) provided 
on August 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection. 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the spinal injection is medically 
necessary due to the enrollee's lumbar radiculopathy. You say that this request is after the three-month period 
and the injection should be approved. The Plan denied your request. The Plan says the epidural steroid 
injections are not medically necessary because the enrollee has not had three months or longer sustained 
improvement in pain relief and/or function of at least 50% from baseline.  
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 epidural steroid injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the information provided does not show at least 50% of sustained improvement 
in pain relief and/or improvement in function measured from baseline using SAME scale for at least three 
months after the first intralaminar epidural steroid injection on September 25, 2023. The plans are for a repeat 
injection with same approach, same location and with the same medication.  The requested lumbar epidural 
steroid injection is not medically necessary or reasonable. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 1, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you passed out at a 
restaurant, but you did not need to go to the hospital. 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 May 1, 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 ambulance treatment without transport provided 
on May 1, 2023.