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

 
We decided that the Plan does not have to pay for the office visit, and lab services provided on March 30, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and lab services. You say that this is supported in the records. 
The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 office visit, and lab services provided on 
March 30, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic devices provided on June 13, 
2023. 
 
You asked the Plan to waive the coinsurance for prosthetic devices. You say that you disagree with the 
coinsurance. 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 20% 
coinsurance for prosthetic devices. 
 
You have been asked to pay 20% coinsurance for prosthetic devices. This item/service falls within the 
prosthetic devices 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 allowed amount for the prosthetic devices is $42.95. You are being asked to pay $8.59 
($42.95 x 20% = $8.59). Therefore, we decided that the Plan does not have to waive the coinsurance for 
prosthetic devices provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 an office visit provided on May 23, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on May 17, 
2023. 
 
You asked the Plan to pay for the principal care management services. 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 the principal care 
management services provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 25 fractions of superficial radiation therapy with image guided radiation therapy (IGRT) (77387, G6002) for the enrollee.
You asked the Plan to pre-approve 25 fractions with IGRT. You say that ultrasound guidance of IGRT will allow the provider to track the progress of treatment and adjust the course of treatment, as necessary. The Plan denied your request. The Plan says that the request cannot be approved because picture studies are not supported to guide your type of treatment.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for 25 fractions with IGRT. Our Medical Director states that there is no documentation that supports that the image guided radiation therapy at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for the patient. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of 25 fractions with IGRT. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 25 fractions with IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve 25 fractions of superficial radiation therapy with image guided radiation therapy (IGRT) (77387, G6002) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not authorized. 
 
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 office visit provided on June 5, 2023, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy provided on February 03, 2023, to 
February 07, 2023. 
 
You asked the Plan to pay for home infusion therapy. You say that this service 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 home infusion therapy 
provided on February 03, 2023, to February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for acupuncture (97810 x3, 97811 x3) provided on April 4, 
2023, to April 25, 2023. 
 
You asked the Plan to pay more for acupuncture (97810 x3, 97811 x3). You say that you would like to be 
reimbursed the rest of the cost for the claim. 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 10% 
coinsurance of the approved amount. The annual deductible applies. The coinsurance and deductible apply to 
the annual out-of-pocket maximus. 
 You have been asked to pay a total of $20.82 for acupuncture (97810 x3, 97811 x3). 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
April 4, 2023 acupuncture, 15 min $39.40 10% $3.94 
April 4, 2023 acupuncture, additional 
15 min 
$29.96 10% $3.00 
April 11, 2023 acupuncture, 15 min $39.40 10% $3.94 
April 11, 2023 acupuncture, additional 
15 min 
$29.96 10% $3.00 
April 25, 2023 acupuncture, 15 min $39.40 10% $3.94 
April 25, 2023 acupuncture, additional 
15 min 
$29.96 10% $3.00 
TOTAL:    $20.82 
 
This item/service falls within the acupuncture for chronic low back pain 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 pay more for acupuncture (97810 x3, 97811 x3) provided on April 4, 2023, to April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74021 billed for date of service April 24, 
2023. 
 You asked the Plan to pay for procedure code 74021. You say that the code was not bundled with any other 
code. The Plan denied your request. The Plan says payment for code 74021 is bundled into payment for code 
74022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 74021 is a column II code to column I code 74022. Code 74021 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74021 
billed for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not authorized. 
 
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 nursing facility care provided on June 1, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 provided on May 
30, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprised of an Outpatient Intravenous Insulin Therapy regimen are nationally non-
covered under Medicare. 
 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 96521 is refilling and maintenance of portable pump. We find that CPT code 96521 is not supported in 
the medical record. The records do not show that this service was provided. 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 procedure codes 96365, 96366, and 96521 provided on May 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 02, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on March 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical dressing provided on April 28, 2022. 
 
You asked the Plan to pay for the surgical dressing. 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 the surgical dressing 
provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a back brace provided on May 12, 2023. 
 
You asked the Plan to reduce the coinsurance for a back brace. You say that you were not told that it was going 
to be super expensive. 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 20% 
coinsurance for in-network prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for a back brace. This item/service falls within the in-network 
prosthetic devices and related supplies 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 $271.84 ($1359.18 allowed amount x 20% =$271.84 rounded up). Therefore, we decided that the Plan does not have to reduce the coinsurance for a back brace 
provided on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement joystick (E2374), expandable controller (E2377), harness (E2313), and an electronic connection (E2311).
You asked the Plan to pre-approve a replacement joystick, expandable controller, harness and an electronic connection. You say that the enrollee needs this wheelchair for mobility. The Plan denied your request. The Plan says that these components are not medically necessity.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a replacement joystick, expandable controller, harness and an electronic connection. Our Medical Director states that provided records document that you have right upper extremity active range of motion within functional limits and no documentation of right upper extremity weakness such that you would be unable to operate the wheelchair's power options with their own switches. Our Medical Director found that your condition does not meet criteria for coverage of a replacement joystick, expandable controller, harness and an electronic connection. 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 replacement joystick, expandable controller, harness and an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement joystick (E2374), expandable controller (E2377), harness (E2313), and an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 28, 2023. 
 
You asked the Plan to pay for the nursing facility care. 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 the nursing facility care 
provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87481) provided on March 2, 2023 to 
March 3, 2023. 
 
You asked the Plan to pay for the lab 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 a panel is a single test with multiple components 
and is characterized by a single unit of service. A panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (87798, 87481) provided on March 2, 
2023 to March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the dental services provided from July 5, 2022, through August 25, 2022.
You asked the Plan to provide additional payment for the dental services. You say that you are seeking coverage under the medical plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that your dental benefit has been exhausted.
The Plan is correct in this case. The file shows that the Plan has approved the maximum yearly benefit of $2,500 for the requested services. There is no provision in the contract which would require the Plan to approve more than this amount. Therefore, we decided that the Plan does not have to provide additional payment for the dental services provided from July 5, 2022, through August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodic evaluation (D0180), the osseous 
surgery (D4260 and D4261) and the occlusal adjustment (D9952) provided by an out-of-network provider on 
January 9, 202, March 2, 2023, and March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that your coverage specifically pays for surgery, and 
you are submitting the claim to support the decision to perform the procedure. The Plan denied your request. 
The Plan says the comprehensive periodic evaluation and the osseous surgery were received from an out-of-
network provider and are not covered by your supplemental benefits. Also, the occlusal adjustment is not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The record shows you received the comprehensive periodic evaluation and the osseous surgery 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. The occlusal 
adjustment is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a comprehensive periodic evaluation (D0180), the osseous surgery (D4260 and D4261) and the 
occlusal adjustment (D9952) provided by an out-of-network provider on January 9, 202, March 2, 2023, and 
March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 05, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you only received a routine 
physical at your visit. 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 $10 
copayment for each visit to a primary care provider (PCP). 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the each visit to 
a primary care provider (PCP) 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 office 
visit provided on June 05, 2023.