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

 
We decided that the Plan does not have to pay for the office visit provided on August 3, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. This service was not routine dental 
care. 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 August 3, 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 subsequent nursing facility care provided on July 26, 
2023, to August 08, 2023. 
 
You asked the Plan to pay for the subsequent 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care provided on July 26, 2023, to August 08, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear stress test and the regadenoson 
injection service provided on June 1, 2023. 
 
You asked the Plan to waive the cost share for the stress test and the injection. You say that you feel that you 
should be reimbursed for the full or a partial amount of the $175 charge. 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 $175 copayment per day, per provider, for each in-network Medicare-covered diagnostic radiology service. The Plan 
contract also says that you must pay 20% coinsurance for each in-network Medicare-covered Part B drug. 
 
You have been asked to pay a $175 copayment for the nuclear stress test. This service falls within with 
outpatient diagnostic tests and therapeutic services benefit category. 
 
You have also been asked to pay $49.59, which is 20% coinsurance of the allowed amount for the injection 
($247.96 allowed amount x 20% = $49.59). This service falls within the Medicare Part B prescription drugs 
benefit category. You have been asked to pay a total of $224.59 ($175 copayment + $49.59 coinsurance = 
$224.59). 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 cost share for the nuclear stress test and the regadenoson 
injection provided on June 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of 
upper extremity provided on July 28, 2023. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI) of upper extremity. You 
say that you were told that this service would be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for other outpatient diagnostic tests including magnetic resonance imaging (MRI). 
 
You have been asked to pay a $50 copayment for magnetic resonance imaging (MRI) of upper extremity. This item/service falls within the other outpatient diagnostic tests including magnetic resonance imaging (MRI) 
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 magnetic resonance imaging 
(MRI) of upper extremity provided on July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) and 
prophylaxis (D1110) provided on October 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you disagree with these charges. 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 Plans 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 D0210 was exhausted on date of service June 9, 2021, and D1110 was exhausted on 
February 28, 2023, and August 2, 2023. Therefore, we decided that the Plan does not have to pay for a 
complete series of radiographic images (D0210) and prophylaxis (D1110) provided on October 12, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health provided on August 02, 2023, to 
August 16, 2023. 
 
You asked the Plan to pay for the outpatient mental health. You say that you are requesting reconsideration for 
the service provided. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 outpatient mental health provided on August 02, 2023, to August 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15005 billed for September 1, 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 procedure code 15005 is not supported. 
 
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 15005 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each 
additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 15005 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. 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 procedure code 15005 billed for September 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 12, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this claim was not billed with the appropriate 
origin/destination modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that or ambulance service claims, providers and 
suppliers must report an origin and destination modifier for each ambulance trip.  
 
In this case, the claim you submitted for these ambulance services failed to include the required 2-digit 
modifier indicating the origin and destination of the ambulance service. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were unaware of this provider being out-of-
network, and feel you should not have to pay for this mistake. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for an office visit provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84154 and 84153 billed for June 12, 2023. 
 
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 there is no separate professional component. 
 
The Plan must follow Medicare rules. The rules say that payment may be made under the physician fee 
schedule for the professional component of physician laboratory or physician pathology services furnished to 
hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they qualify as the 
reassignee for the physician service.  
 
We looked at the file and Medicare rules. The file shows that the billed procedure codes do not have a separate 
professional component. 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 procedure codes 
84154 and 84153 billed for June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 12, 2023.

You asked the Plan to pay for the dental services. You say that the examination was performed because you had acute tooth pain and facial swelling. You also say that this was an acute visit not a regular dental appointment. 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 your benefit for the requested item or service was exhausted on date of service June 27, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 12, 2023.
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).  
You asked the Plan to pre-approve a CGM. You say that you would benefit from this CGM. The Plan denied 
your request. The Plan says the medical criteria for a CGM have not been 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 use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 11, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. 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 proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued use of a home ventilator.

You asked the Plan to provide coverage for continued use of a home ventilator. You say that this device is
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
Maximus partially overturned the Plans denial for transition. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that ventilators may be
covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive
diseases, and chronic respiratory failure due to COPD. Claims for ventilators used to provide CPAP or bi-level
CPAP therapy will be denied as not reasonable and necessary. Three months transition is not necessary based
on how the device is being used. The ventilator was prescribed in April 2022 following a hospitalization in
which you had prolonged mechanical ventilation following abdominal surgery. Compliance data from April 9
to May 8, 2023, show usage of the device for at least 4 hours daily for only 23% of days. Pulmonary function
tests show moderate restrictive lung disease. The diagnosis is obesity hypoventilation syndrome. There is no
diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. BiPAP is the appropriate treatment
for OHS, and the records do not show that this treatment has failed. Medicare does not cover a home ventilator
for the treatment of OHS, or when used at settings that could be provided with BiPAP. You indicate in an
appeal note that compliance issues with the ventilator have been related to depression and medical issues and
you expect to be able to use the device more consistently. However, this statement does not change the fact that
Medicare does not cover the ventilator in the setting it is currently being used. Medicare rules for coverage of
continued use of a home ventilator have not been met. Therefore, we decided that the Plan does not have to
provide coverage for continued use of a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 7, 2023, to July 19, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 Plan had network providers available who were capable of providing the services at issue in this appeal. 
(Please note, items and services received in-network are still subject to any other Medicare coverage rules that 
apply.) The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on 
June 7, 2023, to July 19, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 24, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
paperwork needed for payment. 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 proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nanoknife pulsed electrical field (PEF) ablation 
(0600T). 
 
You asked the Plan to pre-approve Nanoknife PEF ablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Nanoknife PEF ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has favorable intermediate-risk prostate cancer. There is insufficient 
literature to support the safety and efficacy, as defined by Medicare rules, of the requested services. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nanoknife PEF ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Nanoknife pulsed electrical field (PEF) ablation (0600T).